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Full text of "Obstetrical nursing : a manual for nurses and students and practitioners of medicine"

WY 157 B128o 1915 



54430700R 




OBSTETRICAL NURSING 



A MANUAL FOR NURSES AND STUDENTS 
AND PRACTITIONERS OF MEDICINE 



BY X 

CHARLES SUMNER BACON, Ph.B., M.D. 

PROFESSOR OF OBSTETRICS, UNIVERSITY OF ILLINOIS AND THE CHICAGO POLYCLINIC; 
MEDICAL DIRECTOR, CHICAGO LYING-IN HOSPITAL AND DISPENSARY; ATTENDING 
OBSTETRICIAN UNIVERSITY, CHICAGO POLYCLINIC, HENROTIN, GERMAN 
AND EVANGELICAL DEACONESS HOSPITALS 



ILLUSTRATED WITH 123 ENGRAVINGS 




T.rRRARY 

^ mmvi of 

FEB 2 ''915 



LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
19 15 



wY 
i S if 

■ b' \ \ U^U ' d; 

Entered according to the Act of Congress, in the year 1915, by 

LEA & FEBIGER, 
In the Office of the Librarian of Congress. AJ1 rights reserved. 

Transferred from the Library 

Of Congress under Sec. 69, 
Copyright Act of Moh. 4, 1»0» 



JAN -6 1915 ' 



©CI.A391265 



TO 

-MY BEST COUNSELOR AND FRIEND 

MARIE ROSTHORN BACON 

THIS LITTLE BOOK 
IS GRATEFULLY DEDICATED 



PREFACE. 



Obstetrics as a science considers the physiological 
and pathological changes in woman during pregnancy, 
labor, and the puerperium, and as an art it has to do with 
the supervision and care of the reproductive functions 
in woman and especially with assistance during labor. 
The obstetrical art includes the supervision and assistance 
usually given by the physician and the more detailed 
duties performed by the obstetrical nurse. The midwife 
assumes some of the responsibilities of the physician 
while she gives such care as might be rendered by a 
visiting nurse. 

It is evident that obstetrical nursing is a very important 
part of the art of obstetrics. The physician as well as 
the nurse should have mastered its details. He should 
understand how to care for the sick gravida, the suffering 
woman in labor, and the lactating mother just as much as 
the supervising engineer or architect should know the work 
of the employees under his control. In the text-books 
for medical students only a limited amount of attention 
is given to this branch of the art. Practical training is 
often lacking. Much more attention should be given 
to this in the dispensary and hospital obstetrical training 
of students. The needs of the medical student and phy- 
sician have been kept in mind in the preparation of this 
book. 



vi 



PREFACE 



The obstetrical nurse should know as much of the 
science of obstetrics as is necessary for the intelligent 
comprehension of the rules of her art. It is believed 
that the incorporation of the scientific basis for the rules 
will increase instead of detract from the practical char- 
acter of the book. 

In choosing subjects, particularly in dystocia and other 
pathological conditions, it has not been forgotten that 
the nurse is the physician's assistant and should take 
responsibility only when necessary. Certain responsi- 
bilities, however, she must assume. She may be alone 
with the patient at delivery, and she might have to 
contend with a postpartum hemorrhage. Hence such 
subjects are discussed more extensively than would 
be the case could we strictly limit the functions of the 
nurse to assistance. 

The subjects have been presented in logical order. 
No attempt has been made to separate normal from 
pathological conditions, since that would lead to artificial 
divisions and unnecessary multiplication of chapters. 

The illustrations, many of which are new, are intended 
to be practical and to present conditions found in practice. 
I wish to acknowledge my indebtedness to the artist, 
Mr. Thomas Jones, for original drawings and general 
assistance, and to Dr. Frank Ashmore for photographs, 
as well as to the superintendent of the University Hospital 
and to its nurses and staff for kind assistance. 

C. S. B. 

Chicago, 1915. 



CONTENTS. 



CHAPTER I. 



Introductory 17 

Nurse's Duties to Self 18 

Nurse's Duties to Doctor 22 

Nurse's Duties to Patient 27 

Engagements and Arrangements for a Case 30 



CHAPTER II. 

Anatomy, Physiology, and Embryology . . 32 

Pelvis 32 

External Genitals 36 

Mons Veneris, Labia Majora and Minora 36 

Clitoris 37 

Vestibule, Hymen, Vulvovaginal Glands, Perineum . . 38 

Internal Genitals 38 

Vagina 39 

Uterus 41 

Menstruation 46 

Fallopian Tubes 47 

Ovaries 48 

Urinary Organs 49 

Intestines 51 

Peritoneum 52 

Breasts 52 

Embryology 54 

Ovum 54 

Spermatozoon 5 

Fertilization 5 

Segmentation, Embryo and Fetus 5 

Chorion 6 

Amnion, Yolk, Allantois 6 

Umbilical Cord 6 

Migration and Nidation of Egg, Decidua 6 

PltlCGIltcl ^ 

Relation of Mother to Fetus 6 



viii 



CONTENTS 



CHAPTER III. 

Pregnancy 67 

Physiological Changes 67 

Changes in Uterus 67 

Changes in Genital Organs and Breasts 70 

Pathological Changes 71 

Nausea and Vomiting 71 

Constipation '6 

Dental Caries, Nephritis '7 

Toxemia 78 

Frequent Micturition, Edema 85 

Varicosities 86 

Signs of Pregnancy 86 

Abortion 86 

Extra-uterine Pregnancy 88 

Placenta Previa 90 

Separation of Normally Seated Placenta 95 

Cancer of the Cervix 96 

Hydatid Mole 96 

Management of Pregnancy ' . 98 

Diet 98 

Bathing 99 

Dress 100 

Exercise 103 

Care of the Breasts 104 



CHAPTER IV. 



Labor 105 

Eutocia and Dystocia 105 

Causes of Labor 105 

Forces of Labor 106 

Labor Pains 106 

Stages of Labor 107 

First Stage 107 

Effacement of Cervix 109 

Formation of Bag of Waters 109 

Rupture of Membranes Ill 

Second Stage Ill 

Third Stage 112 

After-pains 112 

Mechanism of Labor 113 

Posture 113 

Position, Presentation, Station 115 

Descent 116 

Rotation 121 

Exit of Head 121 

Exit of Body 124 

Expulsion of Placenta 125 



CONTENTS ix 

Management of Labor 127 

Nurse's Outfit, Patient's Outfit ' ! ' ' 128 

Preparation of Nurse 130 

Method of Cleaning Hands 132 

Preparation of Patient 134 

Enema 134 

Closet, Bath 135 

Dress, Bed 136 

Disinfection of Genitalia, Shaving 140 

Solutions 142 

Room 143 

Examination of Patient 145 

Abdominal Examination 146 

Inspection, Palpation 146 

Auscultation 152 

Inspection of Genital Region 155 

Palpation of Perineum 155 

Internal Examination 156 

Care of Bladder and Catheterization 160 

Nourishment 161 

Moral Support . 161 

Analgesia and Anesthesia 162 

Ether and Chloroform 163 

Support of Back 164 

Pulling 165 

Supporting Perineum 165 

Position of Patient 168 

Delivery of Body 168 

Ligation of Cord 169 

Management of Third Stage 170 

Postpartum Hemorrhage 172 

Causes 172 

Atonic Hemorrhage 173 

Hemorrhage from Partial Detachment of Placenta 175 

Traumatic Hemorrhage 175 

Hemorrhage from Deficient Coagulability of Blood . 176 

Inversion of Uterus 176 

Prevention of ... 176 

Removal of Partly Adherent Placenta 177 

Expression of Placenta 178 

Manual Removal 179 

Management of Atonic Hemorrhage 180 

Massage 180 

Hot Douche 181 

Ergot 183 

Summary 183 

Combating After-effects of Hemorrhage 184 

Hypodermoclysis 185 

Dystocia 187 

From Abnormal Forces 188 

From Abnormal Passages 188 



X 



CONTENTS 



Dystocia — 

From Abnormalities in Passenger 

Twins 

Short Cord . . . 

Prolapse of Cord . 
From Abnormal Mechanism 
From Accidents 

Rupture of Uterus 

Vulvar and Perineal Lacerations 
Obstetrical Operations . 

Frequency 

Classification .... 
Preparation .... 
Induction of Abortion 
Induction of Labor 
Dilatation of the Cervix 
Symphysiotomy 
Hebosteotomy .... 

Version 

Changing Face to Vertex . 
Expression of Fetus 
Expressing Head from Vagina 
Manual Extraction 

Forceps 

Cesarean Section . 
Porro-Cesarean Section 
Extraperitoneal Cesarean Section 
Postmortem Cesarean Section 
Vaginal Cesarean Section 

Embryotomy 

Decapitation 

Removal of Placenta .... 

Repair Operations 

Vaginal Douche, Intra-uterine Douche 
Intra-uterine Tamponade 
Hypodermoclysis . 



189 
189 
189 
190 
190 
190 
191 
191 
191 
191 
192 
192 
194 
196 
199 
200 
201 
202 
203 
205 
206 
207 
208 
211 
216 
216 
217 
217 
219 
221 
221 
222 
224 
224 
225 



CHAPTER V. 



PUERPERIUM 226 

Duration 226 

Lochia 227 

Care of Bed, Cleaning of Patient 228 

Puerperal Fever 232 

Symptoms 233 

Treatment 237 

Puerperal Tetanus 239 

Puerperal Insanity 239 

Difficult Micturition 240 

Constipation 243 



CONTENTS xi 



Diet 246 

Breasts, Lactation 251 

Colostrum 251 

Distention 252 

Pumping 253 

Bandage 254 

Ice-bags 258 

Massage 259 

Infection 262 

Galactorrhea 270 

Hypertrophy of Axillary Sweat Glands 270 

Care of Room 270 

Rest 272 

Toilet 274 

Posture 274 

Massage and Passive Movements 275 

Bed Exercise 276 

Getting Up 279 



CHAPTER VI. 

The Infant 282 

First Care 282 

Asphvxia Neonatorum 283 

Treatment 284 

Slapping 284 

Removal of Mucus 285 

Hot and Cold Baths 286 

Laborde Method 287 

Byrd Method 288 

Sylvester Method 290 

Schultze Method 291 

Insufflation 294 

Protecting Child Before Separation 294 

First Care of Eyes 295 

Tying Cord 296 

Condition of Newborn 297 

Malformation 299 

Molding of Head 300 

Caput Succedaneum 300 

Cephalhematoma 300 

Birth Injuries 301 

The Skin 302 

Jaundice 303 

Bath ... . 303 

Cleaning Perineal Region 306 

Care of Navel 308 

Umbilical Hernia 310 

Care of Genitalia 310 

Mensl ruat ion in Inf; mcy 311 



xii CONTENTS 

Ol 1 

Adherent Foreskin j?** 

Circumcision jjjr 

Undescended Testicles . . . • 3 J* 

Care of Breasts q 

Care of Mouth *}% 

Thrush |J« 

Tongue-tie 3J4 

Care of Nose ^ 

Vomiting 314 

Diarrhea 315 

Constipation 316 

Colic • • 317 

Care of Ears 318 

Care of Eyes 318 

Ophthalmia Neonatorum 318 

Subconjunctival Hemorrhage 320 

Dress 320 

Sleep 323 

Feeding 325 

Premature Children 334 

Dangers 334 

House or Incubator Station 334 

Warm Room . 336 

Incubator 336 

Feeding 339 

Oxygen 339 

Dressing and Bathing 339 

Subsequent History 340 

Incubation for Other Debilitated Conditions 340 



OBSTETRICAL NURSING. 



CHAPTER I. 

INTRODUCTORY. 

A nurse's success or failure depends not only upon 
her knowledge of disease and its complications and the 
proper way to manage them, but quite as much upon her 
common-sense and tact in dealing with people and her 
ability to adapt herself to circumstances. When a nurse 
leaves the hospital and enters upon private nursing she 
finds the conditions quite different from those in which 
she has been trained. Sometimes her patient is not 
tractable. When a patient goes to a hospital she assumes 
that she must adapt herself to the regime already in- 
stituted and acquiesces in all the nurse's directions. 
In her own home she does not so easily lay aside her 
authority and the nurse finds it necessary to adopt other 
measures in carrying out the directions of the physician 
than those she is accustomed to use in the hospital. 
Moreover, the household arrangements must be taken 
into consideration. She has to deal with one or more 
servants and must be careful not to cause any disturb- 
ance. She frequently has to manage not only her patient, 
but also her patient's relatives who may have more or 
less authority in the house. Often she has to put up 
with unsatisfactory facilities for doing her work as she 
has been accustomed to perform it. In short, she finds 
private nursing and hospital nursing so different that 
she is often discouraged over her difficulties and mistakes. 
2 



18 



INTRODUCTORY 



If she has the will and tact she will soon overcome these 
difficulties, provided she has the proper foundation of a 
good training in the work she is called upon to do. It is 
the object of this introductory chapter to call attention 
to certain obligations or duties which a nurse owes to 
herself, to her patient, and to the attending physician, 
which, when duly appreciated and regarded will smooth 
over many of the difficulties and bring her a quicker and 
greater measure of success. 

The rules of conduct based upon these duties apply 
more or less to all nursing. Obstetrical nursing differs 
from other nursing in the fact that the obstetrical nurse 
has to care for two patients, the mother and the child. 
Her patients, while helpless, are generally not sick. Her 
duty is to preserve the health of her patients instead of 
to cure them. She is generally engaged beforehand, and 
is the choice of her patient or her physician. If she gives 
satisfaction she is the recipient of much gratitude, and 
her success in her calling is assured. It not infrequently 
occurs that a nurse fails to satisfy her patient or her 
physician, and yet she is quite unconscious of the reasons 
for her failure. It is not uncommon for her in such cases to 
assume that her patient or the physician, or both, dis- 
like her or fail to appreciate her because of some whim 
or unjust prejudice against her. A careful study of some 
of the following suggestions may lead her to clear up her 
ideas and discover where she can improve if she be anxious 
to improve. 

Duties to Self.— The nurse's chief duty to herself is the 
care of her health. Without health she not only suffers 
and risks her future career, but she is unable properly to 
care for her patient. No one who is not strong and free 
from all constitutional or local disease should attempt 
nursing as a calling. If a nurse contracts a chronic disease 
after she has begun her work the question of giving up 
her profession becomes a very important one and must 
be decided by careful study in each individual case. 
Certain diseases are absolutely prohibitive. No nurse 



NURSE'S DUTIES TO SELF 



10 



who has consumption, for example, has a right to con- 
tinue her .work. Syphilis and epilepsy are also examples 
of chronic diseases which absolutely disqualify a nurse. 
Certain pelvic diseases may greatly limit a nurse's useful- 
ness. If a nurse has very painful menstruation, so that 
she is hardly able to be out of bed for two or three days, 
she is certainly not in a condition to properly care for her 
patient. Acute infectious diseases disqualify a nurse, 
of course, until she has recovered. An obstetrical nurse, 
in particular, must avoid all infection both on account of 
the mother and the child. No nurse should think of going 
to an obstetrical case until she has entirely recovered 
from scarlet fever, measles, erysipelas, etc. The greatest 
difficulty in deciding what to do arises in such affections 
as sore throat, colds, and attacks of influenza or grip. 
Should a nurse assume charge of a case of obstetrics or 
remain with a case if she has an ordinary tonsillitis or 
bronchitis? Ordinarily there is here much too great lax- 
ness of judgment. In every such case the nurse should 
consult the attending physician and be guided by his 
advice. If she remain in attendance she should at least 
take all possible care to avoid infecting her patients. 

As a means toward the preservation of her health, she 
must attend to the regulation of her food and drink, 
care of her person, her clothing, sleep, and exercise. 

The kind of food and its preparation will of course vary 
in different houses. Generally she will have no difficulty 
in obtaining a sufficient amount of good, wholesome food. 
A nurse has no right to be whimsical in her diet, and 
should not cause any unusual disturbance in the kitchen 
by asking for uncommon dishes. If she needs, during 
the day or night, an extra lunch, it is perfectly proper 
that she should ask for it in case it is not provided. A 
cup of hot milk is one of the best lunches that can be 
taken, as it is both a stimulant and a food. Sometimes, 
in emergencies, which often occur during the labor, meal 
times are very irregular. At such times a cup of hot milk 
is also very valuable. 



20 



IXTRODUCTORY 



Intimately connected with the question of eating is 
the proper care of the mouth, stomach, and bowels. Good 
teeth and a good stomach are specially valuable when 
there is a lack of good food. A decayed tooth is not only 
a source of suffering but also a cause of improper nourish- 
ment and ill health. Bad teeth and a disordered stomach 
also cause a bad breath, which is a very serious failing in 
a nurse. It is, indeed, so important that it practically 
prevents a nurse from caring for a sensitive or well-bred 
patient. A nurse should always keep her teeth in good 
condition. Upon the slightest sign of trouble she should 
consult her dentist. Even if she has no toothache it is 
well for her to consult her dentist every year at least 
to be certain that no decay is developing insidiously. 
She should, of course, use her brush and powder morning 
and night, and w r ash out the mouth with some mild 
antiseptic wash after each meal. 

If a coated tongue, eructation of gas, or regurgitation 
of food or pressure over the stomach after eating indicate 
a disease of that organ, she should make a vigorous effort 
to improve her digestion. Care of her diet, avoidance 
of indigestible foods, like salads, pickles, fried dishes, 
etc., will be the first measures to suggest themselves. 
A cup of hot water taken before meals will often improve 
the digestion. A regulation of constipated bowels is often 
important. If this care is not sufficient a nurse should 
consult her physician. 

Constipation is a frequent cause of ill health in women, 
and many nurses suffer more or less from this trouble. 
Very frequently it is due to carelessness or ignorance. 
If a girl is taught to secure a regular movement of the 
bowels at a certain time every day she will grow up with 
regular habits. If she is allowed to neglect this important 
function, to attend to the bowels sometimes at one hour 
and sometimes another, and frequently omit caring for 
herself an entire day, she will probably be more or less con- 
stipated. Every nurse should learn the extreme importance 
of a regular daily evacuation of the bowels, and if she 



NURSE'S DUTIES TO SELF 



21 



has not been taught the proper care of herself while a child 
she should make every effort to correct this mistake. In 
case a regular routine is not sufficient she may need 
a laxative diet and medicines and perhaps injections. 
A glass of water taken fifteen to twenty minutes before 
meals is sometimes sufficient as an aid. Frequently 
fruit is quite a help. Coarse foods, including bran and 
agar-agar, are often necessary. Sometimes a laxative 
mineral water or small amount of salts taken in the morn- 
ing for some time will help toward a cure. Any nurse 
who has had any trouble with constipation is advised 
to cure herself before she begins private nursing. The 
circumstances which surround her in a private house 
make it very desirable that she should have no trouble 
of this kind. If she is accustomed to regular habits she 
will have no special difficulty in caring for herself properly. 

The care of the digestive tract suggests the care of the 
skin. It may be impossible to carry out the habit of daily 
bathing, i. e., in a tub. Such a habit is very useful to a 
nurse and should be practised whenever possible. A free 
use of cold water over the neck and chest is a substitute 
to be recommended. Perfect cleanliness to prevent all 
odors of perspiration or exhalation is a matter of course. 
It is hardly necessary to say that the use of perfumes 
about the person is vulgar and disagreeable to the patient. 

The care of the hands will be spoken of when we come 
to consider the subject of disinfection in the preparation 
for labor. It will then appear that clean hands, without 
cracks, hangnails, or any abrasions, unadorned by rings, 
are the most important possessions of a nurse. 

The care of the skin is closely connected with the sub- 
ject of clothing. Loose, comfortable clothes should always 
be worn. They should be warm in winter and afford the 
proper protection at other seasons of the year. Wool 
of the proper weight or wool and cotton or wool and silk 
are the best materials except in the summer. The feet 
especially should be well protected. The shoes should 
have reasonably thick soles and be of sensible shape 



22 



INTRODUCTORY 



and size with rubber heels. A corset which compresses 
the waist just below the ribs is unhygienic and absurd 
for any woman, but especially for a nurse. Her skirts 
should be light. She should rely more for the pro- 
tection of the skin upon the undergarments than upon 
the skirt. The waist and outside skirts are of course 
of washable material. 

A word should be said concerning the night clothing. 
Since an obstetrical nurse is almost certainly called upon 
during the night, when the temperature of the room is 
lower than in the daytime, she must be prepared with 
the proper night clothes. Not only should she have a 
long, warm night-gown with the proper robe, but the 
feet and lower extremities must be protected For this 
purpose pajamas with feet are well adapted. Warm 
slippers are absolutely necessary. A little extra care or 
expense will pay for itself many times over if it preserves 
to the nurse her chief capital, her health. 

An obstetrical nurse is often disturbed very much 
in her sleep, especially during the first week. Unless she 
is able to get along twenty-four hours without sleep she 
should not undertake this branch of nursing. The possi- 
bility that such a demand will be made upon her at the 
beginning of her engagement makes it important that 
she should always go to a case quite fresh and thoroughly 
rested. In the subsequent weeks she generally will be 
able to make up her lost sleep. 

In order to be in the best possible condition she should 
take a brisk walk in the open air of an hour or half an 
hour every day. It may often happen that in the begin- 
ning of a case this is impossible, but, as a rule, it can 
be carried out. The shorter the time that can be de- 
voted to the walk the more wisely should it be em- 
ployed. Breathing deeply with the shoulders thrown 
back with an energetic walk of even fifteen minutes 
will be of value for the entire day. 

Duties to Doctor.— In a broad sense of the term the 
nurse is the doctor's assistant. The doctor alone is 



NURSE'S DUTIES TO DOCTOR 



23 



responsible to the patient for the management and outcome 
of a case. It is not possible or desirable to have a divided 
responsibility. Being responsible it is necessary that the 
doctor should have complete authority. He is respon- 
sible for the nurse and she is responsible to him. From 
this it follows that it is the duty of the nurse to work 
entirely under the doctor's directions. She should assume 
no responsibility on her own account further than may 
be necessary to meet emergencies during the absence of 
the physician. She should under no circumstances insti- 
tute treatment in opposition to that laid down by him. 
If it should be necessary to do something not ordered by 
the physician, she should report to him fully as soon as 
possible her action and the reasons for it. Only in this 
way can she secure and retain his confidence and properly 
perform her duty as his assistant. 

It is never her duty to make, unasked, suggestions to 
the doctor. As a rule only ignorant or superficial nurses 
think to increase their importance and impress the physi- 
cian with their knowledge by making suggestions con- 
cerning the treatment of the case. 

If a nurse should make any mistakes, as anyone may 
do, she should report these mistakes to the physician 
at their next meeting. She will find that he will appre- 
ciate her situation and think more of her for her frankness 
and honesty. Nothing is more calculated to shake the con- 
fidence of a physician in a nurse than to find out later, 
from other sources, of mistakes which she has not reported. 

As the physician's assistant the nurse has to assist or 
wait on him during his attendance at the confinement, 
and his subsequent visits and to carry out his orders 
in his absence. She must also watch her patient and 
report symptoms. In order to carry out the physicians' 
orders it follows, as a matter of course, that the nurse 
must understand him. If she has any doubts as to 
the meaning of any direction she should ask that it be 
thoroughly explained to her. The excuse that she did 
not understand what the doctor meant is no excuse at all. 



24 



INTRODUCTORY 



In order to report properly on the progress of a case 
it is necessary for the nurse to keep a record. The 
report or record of the nurse is of great importance to 
the physician, the patient, and to herself. The patient's 
welfare and sometimes her life depend upon the care with 
which her symptoms are watched and recorded. A mis- 
take in the temperature or pulse will often deceive the 
physician and cause him to overlook an important feature 
of the patient's condition. Failure of the nurse to observe 
some unusual temporary symptom may have the same 
result. Of course a false record is the worst of all. If a 
nurse should forget to take the temperature or pulse, 
and in order to cover up her mistake make a record 
which she thinks is about right, she is guilty of a crime 
against the patient which, at times, might have the most 
serious consequences. 

The nurse's record is of great importance to the phy- 
sician, for it enables him to see in a moment the events 
of the day. If a nurse could know what satisfaction a 
physician takes in a properly kept record, complete yet 
not diffuse, neat and easily read, she would feel herself 
repaid for a little extra care. 

For the nurse herself the record is of importance because 
by it her education, ability, and character are often judged. 
Poor spelling and poor writing stamp a nurse as ignorant 
and careless. A diffuse, mixed-up report shows her to 
be illogical and poorly trained. A neatly written report 
that contains only essential matters marks her as one 
possessed of good mental qualities and proper training. 

It is always desirable that she should form the habit 
of recording each item as soon as observed. Unless this 
habit of making a prompt record is formed she will become 
accustomed to delaying writing for several hours, when 
some things will be forgotten and the record will lose its 
accuracy. If possible the records should be kept in ink, 
being thus permanent and neater. 

Of course the record should be preserved until the case 
is terminated. It is often necessary to refer back to it 



NURSE'S DUTIES TO DOCTOR 



25 



for the history of the beginning of the case. When the 
nurse leaves to whom does the record belong? If the 
physician does not care for it the nurse may preserve it 
if she chooses. It is not good policy, however, for her to 
preserve a number of records in one book. When she 
carries such a case-book from one patient to another she 
exposes the history of a former case to the eyes of strangers. 
The nurse cannot know but what the patient or the 
patient's friends or the physician may take up her case- 
book to look at the record of the patient and almost 
involuntarily notice reports of former cases. A great 
majority of patients would object to this publication 
of the history of their sickness; therefore, if a nurse 
preserves her reports she should keep each case separately. 

Sometimes a physician furnishes the blanks for the 
records, as he wishes to preserve them for future reference. 
The accompanying charts show a form which will per- 
haps serve as a model for childbed and infant records. 
They are kept on cards 10x15 centimeters in size, to 
file away with pregnancy and labor cards. 

Baby Record. 



Name. When born. Birth weight. Page.... 



Hour. 


P. 


T. 


Bowels. 


Urine. 


Navel. 


Eyes. 





















Puerperal Record. 
Name of patient. Date of confinement. Name of nurse. Page. . . . 



Hour. P. 


T. 


Bowels. Urine. 


Lochia. 


Breasts. 


Medicine. 















26 



INTRODUCTORY 



In a system like this as much space can be used as is 
needed. One or two pages or more may be used in a day 
or one page may serve as a record for two or three days. 
A heavy line drawn across the card separates the report 
of one day from another. The date is placed in heavy 
figures in the hour column. The ordinary method of indi- 
cating the time in the hour column for each separate entry 
is, of course, known to all. Any necessary remark con- 
cerning the bowel movement is placed in the proper 
column. The quantity of urine as well as its character 
is to be recorded if possible. During the first two or three 
days the amount and character of the lochia is reported 
in some detail. Later a general observation of the entire 
day may suffice. The condition of the breasts should also 
be noted with some detail. In the last column the facts 
concerning sleep, food, and bathing can be entered. Gen- 
eral observations that might be assumed should be omitted. 
For example, patient washed, patient rubbed, or dressing 
changed are unnecessary items. More explanations for 
the use of the puerperal and baby records will be given 
in subsequent chapters. 

It is often necessary to advise a young nurse upon 
leaving the hospital to engage upon private nursing that 
she should be loyal to the doctor in charge of the case. 
She finds that his practice differs, perhaps in important 
details, from that which she has been taught in her train- 
ing course. She should never comment on this fact to 
the patient or to the patient's friends and compare a 
physician in attendance with some other physician with 
whom she has been associated. Such a course is very 
unwise and will generally react against her. If she, by 
this course, should create a lack of confidence in the 
physician on the part of the patient she may be doing a 
great deal of harm to both parties. She should carry out 
any directions which seem to her useless. It is not 
her business to judge. Loyalty to her physician should 
be her constant motto. If a case should ever arise 
where she is unjustly accused by the physician, she had 



NURSE'S DUTIES TO PATIENT 



27 



better suffer quietly than to bring the matter before 
the patient. In extreme cases where she feels that great 
injustice has been done her, she would better ask the 
advice of the superintendent of her training-school. 

Duties to Patient. — As assistant to the doctor it is the 
duty of the nurse to her patient to carry out his orders. 
This subject has been sufficiently discussed. There are, 
however, duties devolved upon the nurse which are not 
directly comprised in the explicit directions given by the 
physician. These assumed duties may be comprehended 
in the statement that a nurse should secure for her patient 
the best possible physical and mental condition. Both 
are promoted by the proper and skilful care of the patient's 
toilet, care of her room and surroundings, and the general 
conduct of the case so as to prevent worry, anxiety, or 
annoyance. 

In brushing the hair, giving a sponge bath, a douche, 
or an enema a nurse displays not only her training but 
also her habits of attentive tidiness. A nurse who leaves her 
patient or her patient's bed wet or soiled after washing the 
genitals or caring for the bowels cannot expect the best 
recommendations from the most desirable class of patients. 
It is impossible to give explicit directions to a nurse who 
is careless in these respects. Tidiness and cleanliness 
should be part of a nurse's nature. A nurse who makes 
such mistakes after a hospital training of three years is 
hopeless. She may satisfy a slovenly patient and even be 
a favorite in certain classes because of other good traits. 
A first-class nurse will attend to the personal wants prop- 
erly because she herself knows what good breeding desires 
and demands. She knows that if she were in the patient's 
place she would like to have her food, however simple, 
served properly. She would like to have her nurse bring 
her occasionally fresh water without being reminded. 
If she were to ask for a drink of water she would not like 
her nurse to give her a glass of stale, lukewarm water that 
has stood some time in the room. She would not like 
to be obliged to ask for a mouth wash or a tooth-brush. 



2S 



INTRODUCTORY 



Knowing what she herself desires she will have no diffi- 
culty in satisfying any patient. 

The same golden rule that applies to the toilet applies 
also to the room and the surroundings. A refined nurse 
will imagine herself the patient and picture her satis- 
faction with a tidy and well-ventilated room. She would 
appreciate the nurse who knows how to dust the room, 
not by brushing into the air a cloud of dust to settle back 
on the furniture or floor. She would not like to lie and 
look for hours at her dresser in disorder, neither would 
she like to ask her nurse to care for it. She would become 
quite impatient with a nurse who did not know enough 
to care for her flowers at night. The sensitive patient 
regards these things often much more than a knowledge 
of anatomy or medicines. 

A nurse cares for the mental condition of her patient 
more by what she does than by what she does not do. 
A cheerful and quiet manner is appreciated by everyone. 
Some ability to entertain is not to be despised. A gossipy 
nurse is, however, somewhat dangerous. Above all things 
a nurse must avoid speaking of other patients or of the 
affairs of families in which she has lived. Whatever she 
learns of a patient or a patient's family should be held 
strictly confidential. Should a patient be so indiscreet 
as to ask a nurse about such matters she is in duty bound 
to avoid giving answers to such questions. 

A nurse should also avoid the introduction of disagree- 
able subjects. Conversation about diseases in general is 
undesirable. A nurse will soon learn the temperament of 
her patient and subjects that should be introduced. 

A nurse should not ask unnecessary questions. What- 
ever pertains to her work let her find out for herself or 
from servants or other members of the family if possible. 
In an obstetrical case it is always well for a nurse to go 
to the house before the time of the expected confinement 
to learn the arrangements of the house in order that she 
may not need to annoy the patient after the labor begins. 

A nurse should also leave her patient alone at times. 



NURSE'S DUTIES TO PATIENT 



29 



Often a patient wishes rest of which she is deprived by 
the presence and perhaps the conversation of the nurse. 
Let the nurse occasionally withdraw from the room, re- 
maining within call. 

It would seem almost absurd to say that a nurse should 
not use the sick-room for her own toilet, if it were not for 
the fact that this mistake is often made. Trained nurses 
have even been known to use the toilet articles of their 
patients. 

It is a nurse's duty to protect her patient from visitors 
and also from members of her own family. In the per- 
formance of this duty considerable tact and skill must be 
employed. A nurse who would brusquely order from the 
room a husband, a mother, or a sister of the patient may 
be very conscientious, but would never be a favorite. 
Rules must vary according to the case. In general, visi- 
tors are kept out of the sick-room for the first week or 
two and perhaps longer by the doctor's directions. If 
the members of the family tire or annoy the patient, they 
also must be excluded. This can always be done, how- 
ever, in a quiet way that will give no offence. 

One of the chief causes of anxiety to the mother is the 
baby, and the nurse by proper management of the baby 
can do more to make the mother easy and happy than in 
almost any other way. The idea has become quite wide- 
spread that it is the duty of the nurse to begin the training 
of the baby at its birth. Following out this idea she con- 
cludes that the baby should lie in its bed two or three 
hours at a time, when it is to be fed and replaced. If 
the baby cries it is because it is bad and needs strict 
training. Mothers do not fully appreciate the impor- 
tance of this early training and often worry considerably 
over the crying of the baby. This training of a newborn 
infant is overdone. If a baby cries it is because it has 
pain. If a baby is comfortable, warm, clean, and properly 
fed it will sleep quietly most of the time. Walking with 
the baby is generally undesirable. It is the duty of the 
nurse to find out if possible the cause of the baby's dis- 



30 



INTRODUCTORY 



comfort and relieve it. If she cannot discover the trouble 
she must, of course, get the assistance of the physician. 
If both the nurse and the physician fail the nurse must 
make the best of a bad situation and keep the child as 
quiet as she can. Under no circumstances should she 
distress the mother by complaining of the child and call 
it naughty or ugly. A week-old infant is never naughty. 
It is uncomfortable or sick, not because of any fault of 
its own but because of lack of adaptation to its surround- 
ings. A sympathetic nurse who says this to the mother 
will do her duty much better than one who is constantly 
grumbling about the baby or coldly trying to train it. 

Another duty of a nurse to her patient is to serve as 
an example. Through the example of the nurse the 
patient learns the essential ideas of cleanliness. She 
learns how to wash herself and how to care for the breasts. 
If the breast shield must be used she learns from the nurse 
how to clean the shield and the nipple. If artificial feeding 
is necessary the patient learns how to prepare the food 
and how to care for the nursing bottle. The nurse should 
always wash the baby in the proper way in order that the 
patient may learn only the best methods. As an example 
and as a teacher the nurse has a field of great usefulness. 
Her teaching function is by no means one of the least 
of her duties. 

Engagements and Arrangements for an Obstetrical Case. 

— An obstetrical engagement is generally made some time 
before the expected confinement. On account of the diffi- 
culty of determining in advance the exact day of the con- 
finement it is necessary that the nurse should have some 
kind of an understanding with the patient concerning 
the date of beginning and the terms of the engagement. 
While wealthy patients frequently make an engagement 
w T ith a nurse to begin a few days before the expected con- 
finement at a full salary, a great majority of patients 
dislike to pay a nurse before her work begins. It is, 
however, not just for the nurse to wait several days or 
perhaps two or three weeks losing her time. A very 



NURSE'S ENGAGEMENT 



31 



reasonable compromise is that the nurse should receive 
half-pay or part-pay while waiting after a specified date, 
to be determined by the physician. During this time she 
may remain at her home or at the patient's home, as would 
be agreed upon. This plan is especially recommended to 
nurses during the first two or three years of their private 
work. Later their own business ideas will be a sufficient 
guide. 

A nurse should not make any engagements that possibly 
overlap. If, for example, she be engaged for a case for 
four weeks beginning February 1 she should not take 
a case beginning March 1 unless with a distinct under- 
standing with both parties. She should always allow 
one week for the postponement of the first confinement. 

A nurse should always be prepared to go to a case 
without a moment's delay. Her satchel and clothes 
should always be in readiness. She should never go to 
a case of contagious disease for two or three weeks before 
an expected obstetrical case. She ought to arrange for 
permission to leave on a moment's notice any case she 
is attending a fortnight before a confinement case is 
expected. 



CHAPTER II. 



ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY. 

Certain elementary facts concerning the anatomical 
structure and functions of the pelvis and genital organs 
of woman are necessary to an intelligent study of preg- 
nancy and labor. A short description of the chief stages 
in the development of the fetus is also desirable to fur- 
nish an intelligent idea of the growth of the child from 
the egg, its relations to the mother, and the meaning and 
importance of the fetal appendages during pregnancy. 
The most essential facts in elementary form will be given 
in this chapter. 

Pelvis. — The bony pelvis is the lower part of the trunk 
skeleton. It is an irregularly shaped, somewhat curved, 
hollow cylinder, formed of four bones: the two hip bones, 
the sacrum, and the coccyx. The sacrum is formed by 
the uniting together of the five vertebrae below the lum- 
bar vertebne or those of the small of the back. The 
rudimentary last four vertebra 1 of the spinal column form 
the coccyx. Each hip bone, also called innominate bone 
or os innominatum, is formed by three bones: the ilium 
behind and above, the ischium below, and the pubic bone 
in front, which merge early in life into one bone. The 
junction of the pubic bones in front is called the symphysis 
pubis (Fig. 1, Frontispiece). The sacrum and coccyx behind 
with the lower main parts of the hip bones at the sides are 
bound together by strong ligaments and form the walls of 
the small or true pelvis. The upper wings of the hip bones 
at the sides and the lumbar vertebne behind form the 
so-called large pelvis, which partly encloses the lower seg- 
ment of the abdominal cavity. The true pelvis encloses 



PELVIS 



33 



the pelvic cavity, which contains, besides the muscles and 
fascise that line its walls, also the organs of generation as 
well as the bladder and rectum (Fig. 2). The soft pelvis 
is the name applied to the skeletal pelvis lined with mus- 
cles and other soft parts to distinguish it from the hard 
or bony pelvis. It is the obstetrical canal through which 
the child must pass in its birth. 



Fig. 2 




Female pelvis, with thigh hones articulated, showing also the sacro- 
spinoua ligam nts which help to elose the pelvis below. 



The opening into the pelvic cavity from above is called 
the inlet or brim of the pelvis. This plane is somewhat 
heart-shaped, the indentation from behind being formed 

3 



34 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



by the upper part of the sacrum, which is called the pro- 
montory of the sacrum. The exit from the pelvic cavity, 
or the bony obstetrical canal, is called the outlet. We shall 
learn during the study of labor that the pelvic outlet is 
not the same as the true obstetrical exit, namely, the 
vaginal outlet. The space between the inlet and the 
outlet is the cavity or excavation of the pelvis. 



Fig. 3 




Median sagittal section of pelvis. (Gray.) 

The size of the pelvis of a woman is very important, 
for if it is smaller than the child at birth, natural labor 
is impossible. A pelvis which is too small to admit of the 
passage into and through it of the child of normal size 
is called a contracted pelvis. It may be contracted in any 
part of the canal, but it is most frequently contracted 
at the inlet. When it is contracted from before back, 
i. e., when the anteroposterior diameter of the inlet is 
shortened, the pelvis is called a flattened pelvis. When 



CONTRACTED PELVES 



35 



the inlet is equally contracted in all directions, i. e., when 
all the diameters are shortened, the pelvis is called a gen- 
erally contracted pelvis. A funnel pelvis is one in which 
the inlet is normal in size or larger than normal, while 
the outlet is contracted. There are many other forms 
of contracted or deformed pelves, such as' the obliquely 
contracted or Naegele pelvis and the many varieties of 
irregularly contracted pelves. A pelvis may be con- 
tracted irregularly at the brim, at the outlet, or in the 
excavation (Fig. 4). 



Fig. 4 




Three types of contracted pelves: A, irregularly contracted (beak) 
pelvis; B, flattened rachitic pelvis; C, funnel pelvis; D, funnel pelvis, 
sagittal section. 

It is interesting to know the differences between the 
pelves of the child, the woman, and the man. In a child 
the pelvis is comparatively small, narrow, and straight. 
In a girl at the age of puberty, that is about twelve 
or thirteen years, it becomes larger, more curved, and 



36 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



assumes the adult form. The male pelvis is longer and 
narrower. 

Most of the deformities of the pelvis begin in the young 
child when the bones are soft or forming, and are due to 
rickets, a disease which disturbs the growth of the bone. 
Figures representing a sagittal section through a normal 
child's pelvis and a similar section through a rachitic 
pelvis show how the pelvic bones are deformed as a result 
of rickets. It is important to know that this preventable 
children's disease, which is due largely to disturbed nutri- 
tion, is the cause of a large number of difficult labors. 

EXTERNAL GENITALS 

The genital organs in the woman consist of the internal 
organs contained within the pelvic cavity and the external 
organs which form the vulva. The external genitals 
include the mons veneris, labia majora and minora, the 
clitoris, the vestibule, the hymen, and the vulvovaginal 
glands. These, together with the exterior orifices of the 
urethra and the perineum, require a short description. 

Mons Veneris. — The mons veneris or mons pubis is the 
region over and above the symphysis pubis, i. c, the junc- 
tion of the anterior portions of the hip bones. The skin 
is elevated with a fatty deposit and covered with hair. 

Labia Majora. — The labia majora, or large lips of the 
vulva, are broad, elliptical folds of skin containing elastic, 
vascular, and fatty tissues, which pass backward from the 
mons veneris, uniting behind in the fourchette, the anterior 
fold of the perineum, to enclose the vaginal outlet. They 
are more or less covered with hair. The lips lie normally 
in apposition and enclose the other genitals. 

Labia Minora. — The labia minora, or small vulvar lips, 
also called the nymphse, are the folds of very delicate 
skin which lie inside the labia majora. Starting from the 
sides of the latter they converge to the front, where each 
fold divides into two, the lower from each side uniting 
under the clitoris, and the upper uniting above to form 



EXTERNAL GENITALS 37 

its prepuce. The inner surface s of the labia minora are 
in contact. Unless elongated they arc not seen until the 
labia majora are separated. 



Fig. 5 






External genital organs of female. The labia minora have been drawn 
apart. (Giay.) 

Clitoris. — The clitoris is the small sensitive body which 
lies in the middle line and is protected by the upper folds 
of the nymphse which form its prepuce, as just described. 



38 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



The end of the clitoris body is the glans of the clitoris. 
It is generally free from the prepuce, but covered by it. 

Vestibule. — The vestibule is the sensitive triangular 
space lying back of the clitoris, bounded by the labia 
minora on the sides and the anterior border of the vaginal 
orifice behind. Nearly in its centre is seen the opening 
of the urethra, the canal which leads from the bladder. 

Hymen. — The hymen is a fold of vaginal mucous mem- 
brane, frequently crescentic in shape, arising from the 
posterior border of the vaginal outlet, partly closing it. 
It is generally torn after marriage, and if not, always 
after childbirth. The torn edges form an irregular border 
to the vaginal outlet, and these irregularities are called 
the carunculae myrtiformes. 

Vulvovaginal Glands. — The vulvovaginal or Bartholin 
glands lie one on each side at the sides of the vagina behind 
the labia majora and empty by relatively long ducts 
about at the junction of the middle and posterior third of 
the vaginal opening just inside the nymphse. They are 
important in obstetrics, for they are often the seat of a 
chronic gonorrheal infection, which may be the source of 
a contamination of the child's eyes at birth. 

Perineum. — The perineum is the name given to the 
body of muscle and fascia lying between the vaginal 
mouth and the anus. It is about two inches long from 
before back, and extends outward on each side toward 
the diverging anterior branches of the hip bones. The 
perineum is of some importance to the support of the 
vagina. When it is torn, as often happens in labor, the 
proper closing of the vaginal outlet is interfered with, 
and gaping of the vagina results. 



INTERNAL GENITALS. 

The internal genital organs lie partly or wholly in the 
pelvic cavity, and consist of the vagina, uterus, Fallopian 
tubes, and ovaries (Fig. 6). 



INTERNAL GENITALS 



39 



Vagina. — The vagina is a muscular fibrous tube lined 
with mucous menibrane, which is the entrance canal to 
the uterus and the exit for the fruit as well as for other 
uterine discharges. It lies in the pelvis between the 



Fig. 6 




Internal genital organs, with bladder, urethra, and rectum seen from the 

side. 



urethra and bladder in front and the rectum behind. 
The uterus projects into it and carries down the upper 
portion of the tube, which thus forms a kind of collar 
around this projecting vaginal portion of the uterus. The 
upper portion of the vagina which is reflected from the 



40 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 

cervix and forms the upper dome-like end is called the 
fornix of the vagina. This part as well as the middle 
portion or body of the vagina is much larger and more 



Sacrum 



Coccyx 

Recto-uterine 
excavation 
External uterine 
orifice 



Anal canal 




Vesico-uterine 
excaval ion 



Urethra 



Median sagittal section of female pelvis. (Gray.) 



distensible than the lower end or mouth. Hence during 
the passage of the child the lower end is much more fre- 
quently torn. The muscular and fibrous tissues which 
surround, close, and support the vagina are attached 



INTERNAL GENITALS 



41 



directly or indirectly to the walls of the bony pelvis, and 
with similar structures of the rectum form the pelvic 
floor. This is a very important structure, for it helps to 
support the genital organs. It is also often torn or injured 
during labor, when more or less displacement of the 
genital organs results. 



Fig. 8 




Female pelvis and its contents, seen from above and in front. (Gray.) 



Uterus. — The uterus or womb is a pear-shaped, hollow, 
muscular organ, lined on the inside with mucous mem- 
brane, covered in part on the outside with peritoneum, 
the serous membrane that lines the whole abdominal 
cavity. The uterus is divided into two parts, the cervix 
or neck, and the corpus or body. That portion of the 



42 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



neck of the uterus that projects into the vagina is called 
the vaginal portion. Into the upper part of the body 
on the sides are inserted the Fallopian tubes and also the 
round ligaments. The base of the uterus or that portion 
beyond the insertion of the tubes and ligaments is called 
the fundus. The uterus varies in size, being generally 
somewhat larger after a woman has borne children. In 

Fig. 9 

Epodphoron 




Uterus and right broad ligament, seen from behind. The broad ligament 
has been spread out and the ovary drawn downward. (Gray.) 



the virgin it is two and three-fourths to three inches long, 
about one and one-fourth inches belonging to the neck. 
The hollow interior of the uterus is likewise divided into 
two parts: the cavity of the body and the cervical canal. 
The cavity of the body is triangular, the upper angles 
of this triangle corresponding to the openings of the 
Fallopian tubes, and the lower angle or apex corresponding 
to the beginning of the cervical canal. This opening, 



UTERUS 



43 



which of course is at the junction of the neck and body, 
is called the internal os. The opening of the cervical 
canal into the vagina is called the external mouth or os. 



Posterior half of uterus and upper part of vagina. (Gray.) 

When a woman is standing the normal position of 
the uterus is nearly horizontal, the cervix pointing back- 
ward toward the hollow of the sacrum, while the base of 
the uterus lies just below the inlet to the pelvis, pointing 
forward. The uterus, which is slightly concave on its 
anterior or lower surface, lies upon the bladder, while 
the bowels rest upon its upper or posterior surface. It is 
supported at the sides by the broad ligaments that attach 
it to the walls of the pelvis. These are folds of peritoneum 
which enclose the same muscular and elastic tissues and 
the vessels that pass to the uterus. They, however, allow 
considerable motion to the uterus so that it straightens and 
rotates backward as the bladder fills, and forward again 
as it empties. Normally it should rise easily into the 
abdomen as it enlarges. 



Fig. 10 




Uterine 
tube 



44 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 

Ligaments of the Uterus. — The round ligaments arise 
from the fundus in front of the uterine insertion of the 
tubes and pass under the peritoneum outward and forward 
in a curved line to the inguinal canals, through which 
they pass to be inserted into the abdominal walls (Fig. 8). 
When they functionate properly they help to hold the 
uterus in contact with the bladder and prevent too great 
a backward displacement of the uterus when the bladder 



Fig. 11 




Retroversion of the uterus, with coils of intestines between bladder and 

uterus. 

is distended. The uterosacral or posterior ligaments 
of the uterus are folds of peritoneum containing some 
fibrous and muscular tissue, which arise from the sides 
of the posterior wall of the uterus at the junction of the 
cervix and body, pass around the rectum, and are attached 
to the body of the second sacral vertebra. They hold the 
lower part of the body of the uterus backward while the 
round ligaments hold the fundus forward. They thus 
help to keep the uterus in its normal condition in contact 



UTERUS 



45 



with the bladder. If they are weakened or elongated, 
and if at the same time the round ligaments are similarly 
injured, the uterus may change its position so that the 
fundus falls back into the hollow of the sacrum. Coils of 
intestine get between the bladder and uterus, which 
becomes retroverted (Fig. 11). If the junction of the 
cervix or body is thin or soft the uterus may bend back- 
ward and we have a retroflexion (Fig. 12)). When these 
displacements occur during pregnancy they may cause 
troublesome or serious disturbances. 



Fig. 12 




Retroflexion of the uterus. 



Functions of the L 'terns-. — The functions of the womb are 
to receive a newly fertilized egg, nourish the developing 
child from its earliest beginning until it is able to live 
independently, and then expel it. To fulfil these varied 
functions it must be liberally supplied with blood, and 
be lined with a membrane specially adapted to receive 
and support the egg. It must also be muscular to expel 



46 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



the ripened egg. This muscle is an involuntary muscle, 
i. e., it is not under the control of the will. In this respect 
it is similar to the muscle of the intestine or the heart, 
which organs must also work quite independently of the 
will. 

Menstruation. — In this connection one other function 
of the uterus may be mentioned here, namely, menstrua- 
tion. This is a bloody discharge from the uterus, occurring 
every twenty-eight days, that lasts from two to six days. 
Sometimes it occurs as often as every three weeks and 
also as rarely as every six weeks. Greater variations are 
abnormal. When the flow lasts more than six or seven 
days or less than two days and when it is excessive in 
amount it is pathological. Normally there may be a feel- 
ing of fulness in the pelvis and a slight general malaise. 
Backache, cramps, headache, etc., are symptoms of abnor- 
mal condition and constitute a dysmenorrhea. The 
discharge consists of blood cells which pass out of the 
bloodvessels through the walls, or perhaps sometimes 
from ruptured vessels, and cast off cells from the lining 
membrane of the uterus, mixed with a serous fluid and 
mucus. The beginning of menstruation is coincident 
with the changes in a girl which make her a woman. 
Among these changes are the development of the breast, 
the growth and change in the shape of the pelvis, the 
growth of the uterus, etc. This period in a girl's life we 
call puberty. It generally commences at about the age 
of twelve to fifteen years. Menstruation generally stops 
at the age of forty-five to fifty years, when certain retro- 
grade changes occur in the genital organs. This period 
we call menopause or climacteric, or popularly the change 
of life. 

Two theories have been advanced to account for men- 
struation: one is that it prepares the uterus to receive 
the egg, the other is that it results because impregnation 
has not occurred. In favor of the latter theory it may be 
said that a girl may become pregnant before she has 
menstruated, and many women become pregnant while 



FALLOPIAN TUBES 



47 



nursing before menstruation has reappeared. It is quite 
possible that a woman may be carrying or nursing a child 
during all of the child-bearing period and never men- 
struate at all. Menstruation is dependent upon ovulation 
and the changes which occur in the ovary after the rup- 
ture of the follicle and escape of the ovum, i. e., in the 
formation of the corpus luteum. The menstrual dis- 
charge, or periodical escape of blood from the uterus, is 
not the only phenomenon resulting from the menstrual 
changes of the uterus. There is really a cycle of changes 
in the uterus, all probably dependent upon the same 
cause and all important. For a few days before the escape 
of blood the uterus is congested, its mucous membrane 
thickened, there is frequently some fulness of the breast 
and other symptoms. This first stage is the premenstrual 
stage. Then comes the second stage or menstruation 
proper. Then follows a stage of regeneration of the 
mucous membrane of about five days. Finally there is 
a period of rest lasting eight to ten days. 

All of these menstrual changes are of much importance 
not only because of their effect on the life and health of 
the woman, but also because of their obstetrical relations. 
Abnormal conditions may be the cause of sterility or 
of abortion or of diseased condition during pregnancy. 

Fallopian Tubes. — The Fallopian tubes are the canals 
for the passage of the egg from the ovaries to the uterus. 
The sperm cells also pass from the vagina through the 
uterus into the tubes, where they meet the egg and fertilize 
it. The tubes are therefore normally only canals, but 
sometimes an egg lodges in a tube and grows there. These 
cases are called tubal or extra-uterine pregnancies. The 
tube is not adapted to the function of nourishing the egg, 
however, and generally ruptures in a few weeks, producing 
one of the most dangerous conditions. In structure the 
tube is a muscular wall lined with mucous membrane. 
It is about four inches long and lies in the top of the fold 
of peritoneum, which helps to form the broad ligaments 
of the uterus. Each tube opens into the uterus on the 



48 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 

corresponding side near the base by a small mouth. Its 
outer end is trumpet-shaped and opens into the peritoneal 
cavity. It is movable and has been supposed to grasp 
the ovary when an egg breaks free. 

Ovaries. — The ovaries are small bodies, two in number, 
supported by ligaments at the sides of the uterus near the 
walls of the pelvis. They have a fibrovascular tissue 
and contain the unfertilized ova or eggs. The ova are 
very numerous and irregularly scattered through the 



Section of the ovary. (After Schron.) 1. Outer covering. 1'. At- 
tached border. 2. Central stroma. 3. Peripheral stroma. 4. Blood- 
vessels. 5. Vesicular follicles in their earliest stage. 6, 7, 8. More 
advanced follicles. 9. An almost mature follicle. 9'. Follicle from 
which the ovum has escaped. 10. Corpus luteum. 

ovaries, each ovum being surrounded by small cells. 
In a young girl all of the ova are quite small, but during 
the child-bearing period some of them grow and develop 
from time to time into ripe or mature eggs. As a rule one 
egg ripens each month and breaks away from the ovary. 
As the ovum develops it not only grows in size itself, but 
the surrounding cells increase in number and form a cavity 
which becomes partly filled with fluid. During this 
change the ovum cavity, or Graafian follicle as it is called, 



Fig. 13 




URINARY ORGANS 



49 



moves from the interior of the ovary toward the surface, 
where it protrudes, and at last bursts, allowing the escape 
of the ovum. This process is called ovulation. 

Corpus Luteum. — The emptied Graafian follicle develops 
into a very interesting organ, the corpus luteum. There 
is a great proliferation of the cells which line the follicle, 
and these penetrate into the blood clot which fills its inte- 
rior. These cells are called the luteum cells because of 
their yellow color. The yellow body takes on the struc- 
ture and functions of a ductless gland. A secretion is 
formed which, acting on the uterus, causes its mucous 
membrane to become congested and prepared to receive 
a fertilized egg. If fertilization does not occur menstrua- 
tion takes place and then the "corpus luteum of menstrua- 
tion" degenerates and partly, disappears. If fertilization 
and nidation occur, the corpus luteum grows larger, and 
continues to functionate during pregnancy to gradually 
disappear after labor. 

URINARY ORGANS OF WOMAN. 

Before taking up the fertilization and development 
of the egg we must consider for a moment the non- 
genital pelvic organs that may have obstetrical relations 
with the genitalia. Also we must study the breasts, 
which are very important organs in the reproductive 
system. 

The urinary organs consist of the kidneys, the ureters, 
the bladder, and the urethra. The kidneys are excretory 
organs whose function is increased during pregnancy. 
They lie high up in the back above the false pelvis on each 
side of the spinal column and behind the peritoneum. 
Unless displaced they come in spatial relation with the 
uterus only in the latter part of pregnancy. 

Ureters.— The ureters are tubes that convey the urine 
from the kidneys to the bladder, into which they open 
on its under surface. They lie under the peritoneum, and 
in their course bend over the bones that form the posterior 
4 



50 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



wall of the pelvis at its brim. Here they are liable to 
compression by the heavy, gravid uterus, and there may 
occur a dilatation of the upper portion of the tube, with 
consequent disturbance of the kidney secretion. 



Fig. 14 




Diagram showing relation of the urinary organs to the genital organs 
and the pelvis. 

Bladder. — The urinary bladder is a hollow muscular 
organ that acts as the reservoir of the urine, which it 
receives continually from the kidneys and evacuates 
from time to time. It is lined with mucous membrane 
and partly covered with peritoneum. It lies in the pelvis 
between the symphysis pubis in front and the uterus 
and vagina behind. It is held in position by ligaments 



INTESTINES 



51 



which allow a considerable amount of movement. When 
it is empty it lies entirely in the pelvis, and its upper 
surface is flat and in contact with the under surface of 
the uterus. When distended the upper surface becomes 
rounded, and it rises out of the pelvis and the uterus is 
pushed back. The bladder may be injured during labor 
and disturbances are apt to occur during pregnancy and 
the puerperium. 

Urethra. — The outlet of the bladder, the urethra, is, 
in the female, a short tube less than two inches long, that 
passes backward from its opening or meatus in the vesti- 
bule to the lowest point of the bladder. It is closely 
connected with the anterior wall of the vagina, which it 
pushes out in a kind of rounded ridge. 



INTESTINES. 

Some loops of the small intestine lie in the upper part 
of the pelvic cavity, resting upon the upper part of the 
uterus and bladder. These are pushed up out of the 
pelvis as the uterus enlarges in pregnancy. When the 
uterus is displaced backward coils of intestines lie between 
the uterus and bladder. (See page 45.) 

The lower portion of the colon and the rectum lie in 
the pelvis behind the uterus and vagina and in front of 
the sacrum and coccyx. The rectum may be divided 
into two parts, the upper or pelvic portion and the lower 
or perineal portion. The pelvic portion is a continuation 
of the sigmoid colon and begins at the second or third 
sacral vertebrae and ends at the outlet of the bony pelvis. 
Here the muscle which forms the pelvic floor surrounds 
the bowel and begins to be inserted into the lower or 
perineal rectum. The pelvic rectum is called the ampulla, 
and is the fecal receptacle. When empty it corresponds 
to the curve of the sacrum, being concave forward. When 
filled with feces it is cylindrical or spheroid and may 
displace the uterus, vagina, and bladder. 



52 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



The lower or perineal rectum is bent backward, forming 
with the upper portion an S. It is surrounded by a strong 
circular muscle, the sphincter, and except during defeca- 
tion is empty. Its opening at its insertion into the skin 
is called the anus. It is quite vascular, and its veins 
frequently become greatly distended during pregnancy 
or labor and form piles or hemorrhoids. 

PERITONEUM. 

The peritoneum is a serous membrane that lines the 
abdominal and pelvic cavities, covering the walls and 
being reflected over the organs. The pelvic peritoneum 
may be pictured as a membrane that lines the soft pelvis 
pushed inward by the rectum from behind and the bladder 
from the front. Then the uterus and its adnexa push up 
a fold which stretches across from one side of the pelvis 
to the other. Between the layers of peritoneum which 
form these folds are the vessels that supply the uterus and 
tubes. These folds are the so-called broad ligaments. 
Another pair of folds of the pelvic peritoneum pass from 
the sides of the second sacral vertebra around the rectum 
to the junction of the cervix and body of the uterus and 
form the uterosacral ligaments of the uterus. 

BREASTS. 

The breasts or mammary glands (see page 53) are 
situated on the anterior wall of the chest, but are to be 
considered as a part of the reproductive system. Each 
breast is composed of fifteen to twenty lobes, each lobe 
having a duct that empties in the nipple. Shortly before 
entering the nipple it is dilated into an ampulla or a sinus 
lactiferous that is a small reservoir for the breast secretion. 
Following the duct into the lobe we find that it divides 
into many branches, each of which goes between the sub- 
divisions of the lobe called lobules. Further branches of 
the interlobular ducts enter the lobules, subdivide and 



BREASTS 



53 



finally end in dilatations called acini. These are lined 
with the secreting cells and surrounded with a network 
of blood and lymphatic vessels and abundantly supplied 
with veins. 

Fig. 15 




Dissection of the lower half of the mamma during the period of 
lactation. (Luschka.) 



The breasts are but slightly developed in the fetus. 
Some growth occurs shortly after birth and then the 
glands remain quiescent until puberty, when a considerable 
development occurs. 

During pregnancy the glands take on further growth 
and function, and finally after labor they are ready for 
their function, lactation. 

The size and shape of the breast differ much in differ- 
ent individuals and also in the same person at different 
times of life. In general we may say that they are conical 



54 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



or hemispherical, resting on the front of the chest. At 
the most prominent point is the nipple, surrounded by ;i 
pigmented area called the areola. In the areola arc a 
number of sebaceous glands which increase in size during 
pregnancy, and are then called Montgomery's glands. 

EMBRYOLOGY. 

Development of the Egg. — Ovum. — The egg or ovum 
is a cell like all other elements of the body. But unlike 
all other cells it has the wonderful power to unite with a 

Fig. 16 Fig. 17 




Spermatozoa: A, 

Ovum in Graafian follicle. front view; B, profile 

view. 

similar cell from another individual and then develop into 
an independent body. Like other cells the ovum consists 
of a mass of cytoplasm and a nucleus. The nucleus, 



FERTILIZATION 



55 



although much smaller than the cytoplasm, is the most 
important part of the cell, for it is the chief agent in the 
division of the cell, and it contains the fundaments of 
the characteristics of the parent which make the child 
resemble the mother. The ovum has also a membrane 
surrounding it. 



Fig. 18 




Fertilization, four steps. The first shows the penetration by the 
spermatozoon, the second the formation of the male pronucleus from 
the head and body of the spermatozoon, the third the approach of the 
pronuclei, the fourth the merging of the pronuclei. 



Spermatozoon. — The sperm cell, or spermatozoon, looks 
very different from the ovum, as will be seen by the figure. 
It consists almost entirely of nucleus. It has the power of 
independent motion, a power that is necessary to enable 
it to come in contact with the ovum. Sperm cells are 
very numerous in the semen, and a large number find their 



56 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



way into the tubes, where they meet the ovum. Only 
one sperm cell penetrates into the egg. 

Fertilization. — The first step in the development of the 
new being is fertilization or impregnation, i. e., the fusion 
of the sperm cell with the nucleus of the unfertilized 
ovum. After the sperm cell has penetrated the mem- 
brane of the ovum it moves toward the nucleus until 
it meets it and merges with it to form the nucleus of the 
now fertilized egg (Fig. 18). 

Fig. 19 



CO 1 




First stages of segmentation of a mammalian ovum. Semidiagram- 
matic. (From a drawing by Allen Thomson.) z.p., zona striata; p.gl., 
polar bodies; a, two-cell stage; b, four-cell stage; c, eight-cell stage; 
d, e, morula stage. 



Fertilization and the next stages in development have 
never been observed in the human body, but they can 
be carefully studied under the microscope in some animals : 
for example, the fish. Unfertilized fish eggs may be ob- 
tained by pressing them out of the female, and sperm 



SEGMENTATION 



57 



cells are obtained from the male in the same way. The 
eggs and the sperm are brought together in a suitable 
medium and the changes studied under the microscope. 
We have no reason to doubt that the first stages in the 
development of the egg are essentially alike in all animals, 
and hence the description of the development of the 
human egg is completed by supplying the missing stages 
from the study of other animals. 



Fig. 20 




Kroemer-Pfannenstiel Zygote. (From Keibel and Elize's Normalta- 
feln.) The embryonic region is folded into the form of an embryo, which 
is 1 . 9 mm. long, and it is possibly about three weeks old. At the lower 
end of the figure (the caudal end of the embryo) are seen portions of the 
chorion and body stalk. The cerebral portion of the neural rudiment is 
defined. Six pairs of mesodermal somites are present, but there are no 
signs of limbs. 

Segmentation and Beginning of Embryo. — After fertili- 
zation there is a resting stage which lasts for a few minutes 
and then comes the next step, segmentation, or division 
of the cell into two. In this process the nucleus always 
divides first, and then the protoplasm collects around 
each of the new nuclei so that two independent cells are 



58 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



Formed, both contained within the original cell mem- 
brane. We have now the egg in the two-celled stage 1 . 

After another short rest each of the two cells divides 
in the same way as the original cell, and we have the four- 
celled stage. In the same manner the division continues, 
some of the cells perhaps dividing faster than others until 
we have a mass of cells some larger than others, but quite 
small compared with the original cell. This solid mass 
of cells is called the morula or mulberry stage. 



Fig. 21 



Amnion 




Chorion 

Human embryo about fifteen days old. (His.) 

The next step is the so-called blastula. Fluid begins to 
collect in the centre of the mulberry-like mass of cells, 
pressing them apart to form a layer lining the inside of 
the original cell membrane and enclosing a central cavity. 

Soon a thickening appears at one pole of the little 
bladder, which is due to the increased cell multiplication 
in the outer layer. This is the beginning of the embryo, 
and appears in the second or third week. 



EMBRYO AND FETUS 



59 



Embryo and Fetus. — Following this change the embryo 
begins to assume definite form, in that the head end is 
enlarged and the two folds that make up the nervous 
system are beginning to coalesce in the midline. The 
beginnings of the muscles appear as a series of blocks on 
either side. The large yolk mass is apparent below the 
embryo and serves as food substance. The elongated 
mass or ridge of cells now develops more and more, show- 
ing very early the rudiments of the head at one end, and 



Fig. 22 
Heart 




Human embryo, twenty-seven to thirty days old. (His.) 

contains a spinal canal extending along the convex 
surface or back. The body is now partly separated from 
the central mass, henceforth called the yolk, by the fold- 
ing in of the outer layer which forms the surface of the 
body. As the body is thus given its shape the various 
organs develop. The bloodvessels and heart with the 
blood appear very early. The primitive bowel is formed 
as a simple cavity on the under surface by the folding in 



60 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



Fig. 23 

Heart 




Umbilical cord 

Human embryo of about six weeks. (His.) 



FETAL APPENDAGES 



61 



of the outer surface and the separation of cells in the 
interior. Projections appear on the sides of the body 
which form the extremities. As soon as the embryo can 
be recognized as human it is called the fetus. This is 
about the middle of the second month of pregnancy. 

We shall not attempt to describe further the growth of 
the fetus and the development of its parts and organs. It 
will be desirable, however, to show how the egg is fastened 
to the uterus from which it obtains its nourishment, and 
in so doing describe the fetal appendages, in labor called 
" after-birth." We must briefly study the chorion, am- 
nion, yolk sac, allantois, decidua, and the placenta. 



Fig. 25 




A young ovum magnified, showing chorionic villi. Seen from the side 
and from the edge. (Bumm.) 

Chorion. — In the process of development the embryo is 
gradually cut off from the cells outside of the embryonic 
area. The part of the egg not concerned in producing the 
embryo forms two membranes which surround it, the 
chorion and the amnion. The chorion lies immediately in 
contact with the original cell membrane of the ovum. As 
the egg grows the original membrane disappears and the 
chorion becomes the outer coating of the egg. Its outer 
surface is covered with many short, stubby, branching 
projections called villi, which give the egg a shaggy look. 
Meantime the egg has been carried along the oviduct 
until it has reached the interior of the uterus. Here it 
burrows its way into the mucous membrane of the uterus. 
The villi help to attach the egg to the uterus. After its 



62 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 



attachment to one side of the uterus the villi next to the 
surface of the uterus enlarge greatly and help form the 
placenta, while the villi covering the rest of the egg become 
rudimentary. Hence it happens that in examining the 
after-birth after labor the outer membrane, i. e., the 
chorion, seems to be attached to the edge of the placenta. 
In reality the chorion is a continuous membrane and the 
placenta is developed in and upon it. 

Amnion. — The inner membrane enclosing the embryo 
is the amnion. At first it is separated from the chorion 
by a fluid, but eventually they come to lie in contact. 
At the attachment of the cord to the placenta the amnion 
is reflected over it and encircles it as far as the body of the 
child. The way the cord comes to lie outside of the amnion 
will be explained directly when we come to study the 
development of the allantois. The amniotic sac contains 
a liquid which is called the amniotic fluid or liquor amnii 
or fruit water. Its chief function is to furnish protection 
and opportunity for movement to the child. 

Yolk. — The yolk is that part of the egg that is sur- 
rounded by the chorion and partly shut off from the body 
of the embryo. It is at first continuous with the primi- 
tive bowel cavity of the child. As the constricting fold 
of the surface of the body and amnion gradually forms 
the abdominal wall and encloses the bowel cavity it 
constricts that portion of the yolk sac next to the body 
into a thin stalk. This stalk becomes long and thin as 
the contents of the yolk sac gradually are absorbed, until 
it is a mere thread forming a part of the umbilical cord. 
The yolk serves as food for the embryo, but in the human 
it is of comparatively little importance. In fishes and 
birds it is very important, for it is the chief source of 
food for the growing embryo. At birth the yolk sac has 
entirely disappeared or is seen only as a small vesicle 
somewhere in the navel cord. 

Allantois. — The allantois is an important appendage 
of the embryo, for it is the organ which carries blood 
from it to the mother. It is formed as a projection from 



NIDATION OF THE EGG 



c,:; 



the hind end of the primitive bowel. This projection 
passes to the chorion. Its outer end spreads over that 
portion of the chorion which is attached to the uterus. 
The fluid at first contained in the sac of the allantois 
disappears and there remains only the base of the sac- 
attached to the chorion and the stalk connecting it with 
the body of the embryo. In this stalk are the bloodvessels 
which carry the blood from the body to the extended 
surface lining the chorion. These vessels penetrate the 
villi and thus come into intimate relation with the blood- 
vessels of the uterus. 

Umbilical Cord. — From this description it will be seen 
that the cord consists of the elongated stalk of the allantois 
combined with the rudimentary stalk of the yolk sac, 
surrounded by the amnion which, continuous with the 
skin at the small opening in the abdominal wall that allows 
the exit of the allantois stalk is reflected, at the outer 
end, over the internal surface of the placenta and chorion. 
(See p. 62.) 

Migration and Nidation of the Egg. — Decidua. — Before 
describing the placenta it will be necessary to consider 
the changes that have been going on in the uterus during 
the growth of the egg. As soon as impregnation occurs 
the mucous membrane of the uterus begins to thicken, 
and when the fertilized egg reaches its cavity it finds the 
inner surface prepared for its reception. This change in 
the uterus is thought to be due to a secretion derived from 
the corpus luteum of pregnancy. (See page 49.) The 
egg reaches the uterus probably about the end of the 
first week. It has been carried along the tube by the 
movements of the cilia which belong to the cells that line 
the tubal mucous membrane. Muscular contractions of 
the tube may also assist in carrying on its contents. The 
chorion has already become shaggy and the embryo is 
just noticeable. The egg penetrates the epithelial coating 
of the mucous membrane and is soon completely sur- 
rounded by it. Since this mucous membrane is cast off 
with the egg at birth it is called the decidua. That portion 



64 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 

of it which is reflected over the egg is called the decidua 
reflexa. 

Fig. 26 



6 



c 




Semidiagrammatic outline of an anteroposterior section of a gravid 
uterus and ovum of five weeks. (Modified from Allen Thomson.) a, 
anterior uterine wall; b, posterior uterine wall; c, decidua vera; d, 
decidua reflexa; e, decidua serotina; ch, chorion with its villi. 

Placenta. — The chorionic villi are received into the 
decidua. Those next to the uterus develop and form the 
fetal part of the placenta. Those covering the rest of the 
surface of the egg become rudimentary, as has been said, and 
with their disappearance the decidua reflexa also undergoes 
retrograde changes. The decidua corresponding to the 
attached surface of the egg forms the maternal part of 



MATERNAL IMPRESSIONS 



65 



the placenta. It becomes thickened and very vascular. 
The vessels surrounding the villi dilate greatly and become 
practically blood channels, into which dip the placental 
vessels. Some hold that the uterine vessels rupture and 
that the escaping blood flows into spaces around the villi. 
In either case the blood of the fetus is separated from the 
mother's blood only by thin membranous walls. Through 
this membrane pass the food and oxygen from mother 
to fetus, while in the opposite direction pass the waste 
products, including carbonic dioxide. Thus the mother 
supplies the child with food and oxygen by means of the 
placenta. The placenta is therefore the lungs and stomach 
of the fetus. It is composed of two parts: the decidua, 
maternal, the chorion and allantois, fetal. These parts 
are separated as to their origin, but they cannot of course 
be pulled apart mechanically. 

Relation of Mother to Fetus. — From the study of the re- 
lation of the mother to the fetus it appears that there is no 
nervous connection between them. The human embryo is a 
very sensitive being in the earlier stages of its existence ; its 
attachment to the uterus is arranged for the purpose of 
affording it protection and food until it is sufficiently 
developed to live outside of the body. It is, however, 
an independent being from the first, as truly as is an 
embryo chicken. It is evidently impossible for the mother 
to influence the child by any mental impressions. 

This subject is of some importance, for so many mothers 
have a firm belief in maternal impressions, or the possi- 
bility of influencing the child through mental impulses 
that much anxiety is caused through this belief. Most 
women expect to find their first child marked because of 
something they have seen during pregnancy. The first 
question which the young mother asks the physician or 
nurse is this: "Is my baby all right; is it marked?" 
On account of the widespread belief in maternal impres- 
sions and the unnecessary anxiety and unhappiness caused 
by this belief it is desirable that nurses should do their 
utmost to dispel this old notion. 
5 



66 ANATOMY, PHYSIOLOGY, AND EMBRYOLOGY 

Marks or deformities in newborn children are due to 
explainable and unexplainable causes. The red "mother 
marks" that are so often found on the skin are a kind of 
blood tumor. We do not know why they come any more 
than we know why other kinds of tumors appear in later 
life. Some deformities of the fetus are due to conditions 
in the uterus. The fetus may be subject to pressure 
because of an insufficient amount of amniotic fluid. Such 
pressure may result in producing a misshaped head or 
body. Sometimes bands are formed by the fetal mem- 
branes which may constrict a growing limb and perhaps 
even amputate it. Such deformities are explainable, but 
are of course quite independent of the mother. A mother 
should be told that it is her duty to keep herself in good 
condition, to eat proper food, and to dress well for her 
own sake and for the good of her unborn child. If she is 
well the child will be well supplied with nourishment and 
develop properly. She should, however, be told that she 
need not fear maternal impressions. 



CHAPTER III. 



PREGNANCY. 

A woman is said to be pregnant while she is carrying 
the developing embryo. The average duration of preg- 
nancy is 280 days, 40 weeks or 10 lunar months, reckoning 
from the date of the beginning of the last menstruation. 
It is probable that impregnation occurs in the majority 
of cases a few days after the end of menstruation. If 
the menstrual period lasts five days and conception 
occurs five days later, the average length of time from 
impregnation to the birth of the child would be 270 
days. When conception takes place two or three weeks 
after the end of menstruation, the method of finding 
the date of labor by adding 280 days to the beginning 
of the last menstruation does not give us very exact 
results. However, we must in general be satisfied with 
this mode of reckoning. 

We should naturally expect that pregnancy would 
cause a change in the entire body, and such we find to 
be the case. Some of these changes do not effect the 
health of the woman, and hence they may be termed 
physiological changes. Some, however, may cause dis- 
turbances more or less serious, and these we would call 
pathological changes, i. e., changes producing disease. 

PHYSIOLOGICAL CHANGES OF PREGNANCY. 

Changes in the Uterus. — Very shortly after impregnation 
changes occur in the uterus. It becomes congested, i. e., 
a larger quantity of blood is sent to it, and the mucous 
membrane begins to thicken and grow. A brief descrip- 
tion has already been given of the way in which the mucous 



68 



PREGNANCY 



membrane of the non-pregnant uterus is changed into 
the decidua of pregnancy. As the embyro develops 
the entire uterus enlarges^ At the end of the sixteenth 
week it is so large that it lies chiefly in the abdominal 
cavity, i. e., it has risen out of the pelvis. About this 
time, or a little later, the fetus has so far developed that 
it makes rather vigorous independent movements. These 
movements felt by the mother the first time are some- 
times called quickening. It was formerly supposed that 
the child became endowed with life at this time. 

Long before the uterus has escaped from the pelvis, 
and causes an enlargement of the abdomen, the pregnant 
woman has felt that her clothes are too tight, and noticed 
that she is larger than formerly. This enlargement is 
mostly due to distention of the bowels. The congestion 
of the uterus and other genital organs often lead to some 
constipation, and with it fermentation in the bowels 
occurs, causing the abdominal distention. This is not a 
necessary result of pregnancy, but it is so common and 
frequently confounded with enlargement of the uterus 
that it is worthy of mention. 

As the uterus enlarges from week to week its base rises 
higher and higher, reaching the navel by the end of the 
twenty-fourth week, until toward the end of pregnancy it 
has reached nearly to the breast bone, the organ lying in 
contact with the stomach and liver (Fig. 27). It is a 
curious fact that as the base of the uterus ascends the 
white line which runs along the centre of the abdomen, 
called the linea alba, becomes darkened, and is then 
named the linea nigra. Frequently the skin becomes 
stretched, and tears which have the appearance of scars 
occur in the tissue that is underneath the outer layers. 
They are called striae. 

About two weeks before labor the head of the child 
may descend into the lower segment of the uterus and 
sometimes into the pelvis. This allows the base of the 
uterus to descend from its highest position, and is called 
the falling or settling or sinking of the uterus. 



CHANGES IN THE UTERUS 



09 



Fig. 27 




Diagram showing size and height of uterus at different periods of 
pregnancy. 



70 



PREGNANCY 



Changes in all the Genital Organs.— Not only the uterus 
but also the vagina and the other genital organs become 
congested when impregnation occurs. This congestion 
of the vagina deepens its color to a deep blue or purple. 
The uterine ligaments, especially the round ligaments are 
increased in length and size. 



Fig. 28 




Breast of pregnancy or lactation showing Montgomery's glands and 
areola. 

Changes in the Breasts. — In the first pregnancy there is 
generally a marked development of the breasts. The 
enlargement sometimes leads to such a stretching of the 
skin that strife appear similar to those in the skin of the 
abdominal wall. The breasts not only become perman- 
ently filled with blood, but new glandular tissue forms. A 
secretion, the colostrum appears, which may be expressed 
from the nipple or sometimes shows spontaneously. The 
areola outside of the nipple darkens, the little circle of 
glands, surrounding the nipple, called the glands of Mont- 



NAUSEA AND VOMITING 



71 



gomery also become prominent. In the later pregnancies 
the same changes occur with the exception of the develop- 
ment of new glandular substance (Fig. 28). 

Coincident with these changes in the genital organs, 
occur certain changes in the entire body that need not be 
described in detail. It is, however, well to mention that 
an increased sensitiveness of the central nervous system 
generally exists. It becomes more sensitive to external 
stimulation; particularly is it more sensitive to stomach 
irritations. The bearing of this change in the nerve centres 
on the diseases of pregnancy will shortly appear. 

One of the noticeable changes of pregnancy, and to the 
woman frequently, the first sign of her pregnancy is the 
cessation of menstruation. Generally there is no true 
menstruation after pregnancy occurs. Any discharge of 
blood during pregnancy is always suspicious. It usually 
indicates either a threatened abortion or an improper 
location of the placenta. 

PATHOLOGICAL CHANGES OF PREGNANCY. 

Nausea and Vomiting. — Nausea and vomiting are so 
common that they are often considered necessary accom- 
paniments of pregnancy. That, however, is not true. 
About one-third of all pregnant women escape this trouble, 
and no doubt proper management of pregnancy would 
reduce the amount of nausea considerably. It is proper 
then to call this symptom pathological and not physio- 
logical. 

In mild cases there is only a feeling of nausea on get- 
ting out of bed in the morning. Hence arises the common 
term "morning sickness." When the trouble is a little 
more severe, vomiting also occurs at the same time. 
Later in the day nausea disappears and the patient is 
able to eat and retain lunch and dinner. In still more 
severe cases the nausea lasts all day, and sometimes the 
patient is unable to retain any food. In these latter cases 
we have what is called excessive or pernicious vomiting. 



72 



PREGNANCY 



Sometimes the technical terms, emesis and hyperemesis, 
corresponding to vomiting and excessive vomiting, are 
used. 

Nausea and vomiting occur generally in the first three 
or four months of pregnancy and disappear completely 
in the later months. Nausea sometimes begins during 
the first month before the patient by the failure of men- 
struation has become aware of her pregnancy. Generally 
it is noticed in the early part of the second month. Occa- 
sionally the nausea continues throughout the entire preg- 
nancy. Nausea beginning in the later months of preg- 
nancy is generally of a different kind from that occurring 
in the beginning of pregnancy, and due to other causes. 

While it would be impossible to enter into a satisfactory 
discussion of the causes of the vomiting of pregnancy, it 
is desirable to mention that a poor circulation of blood 
is an important factor. The congestion of the pelvic 
and abdominal organs means that an unusual amount of 
blood is accumulated in them. It follows that less blood 
is in other parts of the body. The extremities are apt 
to be cold. Less blood is sent to the brain. There is a 
condition resembling chronic shock. The brain centres 
become particularly sensitive to outside irritation. The 
vomiting centre is easily excited. The heavy, congested, 
perhaps misplaced uterus, or the constipated bowel or 
the stomach or intestine distended by fermentation gases, 
are sources of irritation. 

Management of Emesis. — The responsibility for the 
management of severe cases of nausea and vomiting must 
be of course with the physician. It would be well if all 
women would consult their physician at the beginning of 
pregnancy. Much of the discomfort which so many think 
a necessary accompaniment of pregnancy could be pre- 
vented by proper hygienic management. It often happens, 
however, that the physician is never consulted in mild 
cases, while a nurse often has opportunity to give good 
and valuable advice. Hence it is desirable that she 
should know what should be done in simple cases. The 



H YPEREM ESIS GRA VI DA R UM 



73 



line of management is easily discovered from a considera- 
tion of the cause of the trouble. A good circulation is 
most important. The overfilled pelvic and abdominal 
organs should be relieved by the stimulation of the 
circulation in the surface of the body. In the morning 
the patient should remain in bed in the horizontal posi- 
tion until a good circulation is secured. One of the best 
means is for the patient to take a hot drink, a cup of 
hot milk, for example, while in bed. In half an hour she 
may be able to get up without much trouble. She should 
spend but little time with her toilet. Let her get out of 
her room into the fresh air as soon as possible. Then 
let her take a light breakfast. Sometimes it is best for 
her to take breakfast in bed. In addition, she must care 
for the excretions. She must under no circumstances 
allow herself to become constipated. The management of 
constipation if it is at all obstinate must be left for the 
physician. She must dress warm in order that the skin 
circulation may be kept in good condition. By attention 
to these rules the ordinary cases of nausea and vomiting 
can be satisfactorily managed. 

Management of Hyperemesis Gravidarum. — Although in 
pernicious vomiting the physician is in charge the out- 
come will depend very much upon the nurse. Hardly any 
other kind of a case tests as does this the nurse's skill, 
tact, courage, and endurance. The neurotic element is 
predominant in the causation of this disease. The 
majority of patients are hysterical, and those who have 
never had well-marked hysterical attacks have inherited 
a sensitive nervous organization that makes it difficult 
for them to withstand the strain of pregnancy. Fre- 
quently the patient did not want to become pregnant 
and would like to have an abortion produced. She has 
been accustomed to have her own way and rebels against 
all measures of restraint. She easily becomes panicky, 
fears death, and requires constant moral support to keep 
her from despair. At the same time the husband, other 
relatives and friends, who are all accustomed to gratifying 



74 



PREGNANCY 



every whim of the patient, give no help in the management, 
but on the contrary seek to interfere through sympathy 
for her or through fear for a fatal outcome. 

It is preferable to have such a patient in a hospital. 
There she expects to find a certain routine and is prepared 
beforehand to submit. The interference of friends is 
mostly absent. The nurse can get more help and relief 
from constant attendance, and she can also get moral 
support from the superintendent of nurses. 

If the patient remains at home the first thing for the 
nurse to do is to get control of the situation. If she has 
had experience in the care of nervous cases she has a 
great advantage. She must be very kind and very patient. 
Often she must regard her patient as an irresponsible, 
spoiled child and pay no attention to her moods. She 
must be always cheerful and radiate encouragement and 
hope and confidence. 

The treatment of the physician will probably consist 
in absolute rest in bed, withdrawal of all foods and liquids 
by the mouth, cleansing and nutrient enemata, perhaps 
stomach lavage and medicine to produce sleep. The 
patient is kept in the horizontal position without a pillow, 
or with only a very small pillow because this position 
favors the flow of blood to the brain. Sometimes it is 
desirable to lower the head by raising the foot of the bed. 
All attempts at vomiting must be avoided as much as 
possible. They do only harm. Frequently a little ammo- 
nia w T ater, smelling salts, alcohol, or vinegar held before 
the nose will prevent a vomiting attack. If the vomiting 
attack cannot be stopped, the patient must not be allowed 
to sit up and retch violently for some minutes. Instead, 
the nurse must turn her gently to the side and support 
her head just over the edge of the bed. The patient 
should be encouraged to control the retching and resume 
the dorsal position as soon as possible. Some volatile 
stimulant like ordinary smelling salts will often aid in 
such control. 

Taking nothing into the stomach is frequently the 



HYPEREMESIS GRAVIDARUM 



75 



quickest and best way to success. Should this order be 
given the nurse should carry it out strictly, of course. 
Sometimes the physician allows the patient five to ten 
drops of water in the mouth every ten minutes. This 
amount is absorbed before reaching the stomach. The 
great thirst from which the patient suffers is relieved by 
enemata. Normal salt solution enemata are given for this 
purpose. Each day one large enema of two to four quarts 
can be given to clean out the bowel and two or three small 
enemas of six to eight ounces to be retained. Salt solution 
may be also given by the drop method. Of course all of 
these must be given with proper technique in order to avoid 
disturbing the patient as much as possible and to be effi- 
cient. The temperature of the solution and the rate of 
injection must be considered. A large injection should be 
given with a rectal tube and the patient should lie with 
the hips elevated. When cramps occur the flow should be 
stopped, the irrigator tube disconnected from the rectal 
tube and some of the injection or eventually gas should be 
allowed to escape from the latter until the patient is 
comfortable, then the injection should be resumed. 

Sodium bromide is sometimes used in proper doses to 
replace the sodium chloride or common salt in the salt 
solution when the quieting effect of the bromide is neces- 
sary. Other sedatives or hypnotics may also be given 
in solution. 

Some physicians add small doses of alcohol to the enema 
for its stimulating effects and also as a food. Nutritive 
enemata containing milk, eggs, digested meat, etc., are 
undesirable in this condition, for they generally render the 
rectum and colon irritable after a short time. Alcohol has 
a considerable food value, two ounces being equal to about 
twenty ounces of milk, and it has the great advantage 
that it is readily absorbed and does not in proper dilution 
disturb the bowel. 

Under no circumstances should the nurse try to carry 
the tube into the colon unless she is expressly directed to 
do so by the physician. The so-called colonic flushings 



70 



PREGNANCY 



are almost always delusions. It is very difficult to carry 
the tube through the sigmoid above the brim of the pelvis. 
It generally coils around in the ampulla of the rectum and 
may injure the mucous membrane of the bowel or irritate 
the uterus. 

The stomach frequently contains large quantities of 
mucus and sometimes the contents of the intestine have 
been carried back into the stomach by reverse peristalsis 
induced by vomiting. This mass is foul and irritating, 
made worse by fermentation set up by numerous yeast 
germs. It is not completely emptied by vomiting. There- 
fore it is often a good plan to wash out the stomach. This 
procedure may have also a very good moral effect on the 
patient. Frequently the lavage is followed by the intro- 
duction of milk. It is somewhat remarkable that a patient 
can retain and digest a pint and a half of milk introduced 
into her stomach without her knowledge, while she could 
not retain half an ounce taken by the mouth. 

The induction of abortion for the pernicious vomiting 
of pregnancy is almost never necessary when the patient 
can be properly managed. Patients and their friends are 
only too ready to demand this extreme measure. The 
nurse should under no circumstances suggest it. On the 
contrary, she should always encourage her patient, for 
the most extreme cases, if uncomplicated, have very good 
chances. The treatment may last some weeks, generally, 
however, not more than two or three, and then recovery 
is apt to be very rapid. 

Constipation. — Constipation is a condition so common 
in pregnancy, and at the same time so important as a 
source of disturbance during pregnancy, and during 
childbed, that it is well for a woman to know its impor- 
tance in order that she may be alert to avoid it and its 
consequences as far as possible. Pelvic congestion, lack 
of the usual exercise, changes in diet, and in the later 
months, pressure of the large uterus on the colon, are 
the chief causes of constipation. Distention of the bowel 
by fermentation gases is one result. Chronic poisoning 



NEPHRITIS OF PREGNANCY 



77 



of the body by absorption of poisons from the sluggish 
bowel is another. In the later months of pregnancy, 
the gases may cause considerable disturbance by inter- 
fering with breathing. In childbed vigorous efforts to 
remove the accumulation of feces sometimes causes con- 
siderable poisoning, leading to fever. Constipation may 
be prevented by attention to diet, daily habits, exercise, 
etc. Drinking freely of water, eating laxative foods and 
as much fresh fruit as possible are often sufficient. A 
cup of hot water with a little salt taken fifteen to 
twenty minutes before meals is beneficial. The further 
management of constipation should generally be left to 
the physician. Taking of strong cathartics should under 
all circumstances be avoided, for they may lead to abortion. 

Dental Caries. — Occasionally a pregnant woman is 
troubled with a rapid decay of the teeth. It is a common 
idea that the substance of the teeth is absorbed for the 
purpose of furnishing matter for the bones of the child. 
This is a mere fable with no scientific foundation. The 
ordinary causes of tooth decay, that is, poor circulation 
in the gums, lowered resistance of the tissues and the 
presence of bacteria are particularly active during preg- 
nancy. To prevent decay, a woman should be particu- 
larly careful to keep the mouth in good condition, using 
a mild antiseptic tooth wash and a brush freely. She 
should also consult a dentist at the beginning of preg- 
nancy and have all cavities filled. She should inform the 
dentist of her condition, and he will of course avoid giving 
her long sittings, or cause her much pain. For large 
or painful cavities, temporary fillings should be used. A 
hopelessly bad tooth should be extracted. 

Nephritis of Pregnancy. — Changes in the kidneys are 
perhaps the most important pathological changes that 
occur during pregnancy. These take place chiefly in the 
latter part of pregnancy. The kidneys become tempo- 
rarily inflamed and fail to excrete properly. Sometimes 
the amount of urine passed is very much decreased. Again 
the quantity of urine may be normal but the amount of 



78 



PREGNANCY 



solids is greatly lessened. The kidneys may also allow 
the passage of albumin from the blood into the urine. 
This is called albuminuria. 

As a result of this deficient action of the kidneys, the 
waste products of the body begin to accumulate and to 
produce symptoms of poisoning. As a result of changes 
in the blood and in the circulation, fluid collects in the 
tissues outside of the bloodvessels and we have general 
edema or dropsy. This is most marked in the lower 
extremities, especially during the day when the patient 
is on her feet. In the morning there is swelling of the 
face, which is especially noticed under the eyes. If the 
trouble becomes serious, the skin swells and pits on 
pressure. The internal organs also become edematous; 
for example, the breathing becomes difficult, on account 
of the edema of the lungs. 

Other results of this self-poisoning or auto-intoxication 
by the waste not excreted by the kidneys are headache, 
dizziness, disturbance of vision, and sometimes nausea, 
vomiting, and diarrhea. This nausea and vomiting occur- 
ring late in pregnancy resulting from kidney disease is 
quite different in its nature and importance from the 
so-called "nausea and vomiting of pregnancy" that have 
already been described. 

With the appearance of headache and disturbance of 
vision the condition becomes very threatening. The 
patient is in great danger of that most dreaded of all com- 
plications, eclampsia, or convulsions. These convulsions 
are quite similar to uremic convulsions occurring outside 
of pregnancy due to disease of the kidneys. 

Disease of the kidneys is not the only factor, however, in 
the causation of eclampsia. One of the functions of the 
liver is the breaking up of poisons so that they may be 
excreted by the kidneys. This function is often inter- 
fered with in pregnancy because of changes in the liver 
caused by the same poisons that injure the kidneys. 

Toxemia of Pregnancy. — According to the theory now 
most generally accepted, these poisons of pregnancy are 



ECLAMPTOGENIC TOXEMIA 



70 



produced by the egg or the fetus. As you have learned in 
the study of physiology, all living cells give off waste 
products which are poisonous. These are the so-called 
metabolic poisons. They enter the blood of the mother 
and must be eliminated promptly, else they accumulate 
so as to poison her tissues, especially the delicate nerve 
elements. Sometimes by reason of the rapid production of 
ovular poisons, for example, in twin pregnancy, or because 
of deficient activity in the liver and the excretory organs, 
the metabolic products accumulate and the condition 
of toxemia or blood-poisoning results. As these poisons 
tend to produce convulsions or eclampsia we call this 
disease "the eclamptogenic toxemia of pregnancy." 

This toxemia is really the cause of the liver and kidney 
disease. There are also changes in the blood and blood- 
vessels and in other organs and tissues of the body. The 
most marked symptoms of this disease are, besides the 
albuminuria already noted, edema, increased blood- 
pressure, disturbance of vision, headache, dizziness, 
nausea and vomiting, and finally eclamptic convulsions. 
The latter should be regarded as a symptom denoting 
that the disease has reached its climax rather than as a 
disease itself. 

Eclamptic convulsions occur sometimes during preg- 
nancy when they may or may not bring on premature 
labor, or they may come on during labor, or lastly they 
may appear during the puerperium. The name puerperal 
convulsions, commonly used, would only apply to the 
latter. Whenever they occur they are of the same nature, 
and may be regarded as the outbreak of the nervous system, 
showing that it has been poisoned, so that it is beyond 
the control of the ordinary restraining influences. An 
eclamptic convulsion is a spasm of all muscles of the body. 
The patient is quite unconscious. The extremities, head 
and body, are in violent motion, while the face twitches 
horribly. If the tongue gets between the teeth, as often 
happens, it will be badly bitten by the movements of the 
jaw. The convulsion comes on suddenly. It lasts from 



80 



PREGNANCY 



one to two minutes, and ceases with the patient purple 
from the obstructed respiration and apparently very 
much exhausted. She generally remains in a comatose 
state for fifteen to thirty minutes, when she gradually 
regains consciousness and goes into another convulsion. 
The frequency and severity of the convulsions is an index 
of the seriousness of the case. Death may occur during a 
convulsion from failure of respiration or it may follow after 
several hours from exhaustion resulting from the poisoning. 

The prevention of eclampsia requires the early recog- 
nition of the eclamptogenic toxemia. All of the symp- 
toms above given are important, but albuminuria has 
always been considered most serious. Hence the study 
of the condition of the urine becomes one of the most 
important duties of the physician. The obstetrical nurse 
should be sufficiently informed on this subject to be able 
to advise the patient of the importance of a timely con- 
sultation with the physician, and particularly as to the 
serious meaning of the chief symptoms of headache, 
dizziness, and general dropsy in pregnancy. She may also 
be called to care for a patient threatened with convul- 
sions, and may be asked to make elementary examinations 
of urine. 

An accurate collection of urine is of first importance. 
It is necessary to know the quantity of urine excreted 
in twenty-four hours. Then a sample from the whole 
amount will give its average composition and tell the 
activity of the kidneys. The urine should be free 
from foreign substances, including the bacteria, that 
cause its decomposition outside of the body. Urine 
is generally collected in an ordinary chamber-vessel. 
This will answer if the vessel is scalded well and kept 
covered the whole day or during the period of collection. 
Then the urine is shaken up, well measured, and a sample 
of at least three ounces put into a perfectly clean bottle. 
In case there is no measure in the house a drinking glass 
may be used, measuring it by filling it with a bottle of 
known size, for example, a two-, three- or four-ounce 



EXAMINATION OF URINE 



81 



bottle. The ordinary drinking glass holds about eight 
ounces. 

Experience shows the necessity of explaining what is 
meant by collecting urine for twenty-four hours. It is 
not meant to collect the urine passed from the bladder, 
but the urine passed from the kidneys. Hence if we begin 
the collection a 8 a.m., for example, the bladder must be 
emptied at that hour, but the specimen not saved for it 
has been accumulating perhaps all night. Then all the 
urine passed until 8 a.m. the following day is saved. This 
represents the kidney excretion for twenty-four hours. 

If the physician does not require the urine for twenty- 
four hours the nurse should always note on the history 
sheet the amount passed at each time. A specimen of 
the urine passed at any time may be used for examination 
if the time of its excretion is known. 

The examination that the nurse is sometimes required 
to make consists in the determination of the specific grav- 
ity, the reaction, and the presence or absence of albumin. 
To determine the specific gravity of urine or its weight 
compared with water the urinometer is used. This is a 
weighted glass bulb with a graduated stem reading from 
1000 to 1040 The bulb put into urine, generally con- 
tained in a long, small, cylindrical vessel, sinks more or 
less according to the density of the urine. In average 
normal urine it sinks to the 20 mark, which denotes that 
the urine is 20 thousandths heavier than distilled water, 
i. e., its specific gravity is 1020. In taking this specific 
gravity the urine should be at the temperature of a living 
room, i. e., about 70° F. 

The chemical reaction of the urine is determined by 
litmus paper. Red litmus paper remains red in urine 
that is acid and turns blue in alkaline urine, while blue 
paper remains blue in alkaline urine and reddens in acid 
urine. Urine that is neutral, i. e., neither acid nor 
alkaline, does not affect either kind of paper. 

The heat test is used in examining for albumin. Albu- 
min in urine, like the white of egg or most other kinds 
6 



82 



PREGNANCY 



of albumin, coagulates when heated. To apply the test 
a test-tube, an alcohol lamp or gas burner, a small funnel, 
acetic acid, and filter paper are necessary. The test-tube 
is filled one-half or two-thirds full of filtered urine and 
held slanting over the flame so that the upper part of the 
column of urine is heated. If albumin is present it shows 
as a more or less dense cloud in the heated urine, well 
contrasted with the clear cold urine in the low r er part of 
the tube. If the urine is not acid a few drops of acetic 
acid must be added to it before applying the heat test. 

In caring for a case of toxemia the nurse may be also 
required to take the blood-pressure daily or more fre- 
quently. Either a mercury or a spring instrument is 
used. The technique of applying the cuff or armband 
and reading the pressure when the pulse disappears is 
simple and should be mastered by every nurse. 



In the milder cases of eclamptogenic toxemia of preg- 
nancy the duties of the nurse consist in a careful observa- 
tion of the patient, and teaching her how to carry out 
exactly the physician's directions. These include care 



Fig. 29 




Sphygmomanometer in use. 



ECLAMPTOGENIC TOXEMIA 



83 



of the diet, the excretions, and the regulation of the 
exercise. The diet is a more or less strict milk diet. Fruit 
in considerable quantities may generally be allowed. 
Starch foods like rice, etc., are also permitted if well 
cooked. Meats, including meat soups, are forbidden. 
In emergency cases it is best to withhold all foods for 
two or three days. The bowels should be moved two or 
three times a day. The skin is kept in good condition 
by frequent baths and warm woollen clothing. The pa- 
tient should never become tired. If she must remain 
much in bed she should have massage and passive move- 
ments to keep her in good condition. 

In most severe cases when, for example, there may be 
considerable disturbance of the respiration from dropsy 
of the lung it may be necessary to increase the excretion 
from the skin by giving the patient a sweat every day. 
For this purpose a hot wet pack or a hot-air or vapor 
bath may be employed. The hot-air and the vapor baths 
may be given in bed or with the patient sitting. In the 
latter case the tent is very cheap and convenient The 
patient sits on a wooden-seated stool or chair, under which 
is the alcohol or gas burner. Over the flame may be 
placed a pan with plain or medicated water. If the vapor 
bath is given the patient should be carefully watched 
during the bath. If she becomes exhaused or dizzy the 
bath must be stopped. A cold compress on the head 
is generally agreeable. When the bath is finished the 
patient should be wrapped in a woollen robe or blanket 
and put to bed while rolled in blankets. There she should 
lie for half an hour, when she is to be well rubbed and 
dressed in warm dry flannels. 

When a hot-air or vapor bath is to be given in bed the 
patient should lie upon or be wrapped in a flannel blanket. 
Over her is placed a frame extending from her shoulders 
to her feet. Covering this frame is a rubber cloth, or an 
oil-cloth, over which are blankets that are carefully tucked 
around the patient's neck. The hot air or vapor is intro- 
duced into the space surrounding the body by means of 



84 



PREGNANCY 



a small tube or pipe, like the pipe of a gas stove. A double 
pipe or one covered with asbestos, which does not get so 
hot on the outside, is better than a single pipe. At the 
foot of the bed a burner is placed, on which stands a 
vessel with liquid, in case vapor is to be used. The pipe 
is bent at right angles by means of an elbow, and supported 
by wire at the foot of the bed, conducts the hot air or 
steam under the frame. The patient must be watched 
as in the tent, and the after-care is of course the same. 

Sometimes the ordinary wet pack is employed. This 
is generally used in emergencies, but when a number of 
sweats are given the tent or bed-frame is generally pre- 
ferred. The technique of the wet pack is so well known 
as to require no description. 

If convulsions have already occurred, in the absence of 
the physician, the nurse should get the patient into bed, 
remove the clothing, wrap her in woollen blankets, and 
keep her from all external disturbance. No noise should 
be allowed, and no one except those needed for help should 
be permitted to remain in the room. During a convul- 
sion the nurse must protect the mouth and tongue from 
injury by at once introducing a fair-sized wooden mouth 
gag. If the convulsion is very severe, and respiration 
stops, it may be necessary to employ artificial respiration. 
Under no circumstances should she give chloroform or 
other anesthetic unless ordered to do so by the physician. 
If the patient comes out of the stupor following a con- 
vulsion and wishes a drink of water that may be given, 
although the irritation of swallowing may bring on a 
convulsion. Nothing should be forced on the patient. 
While waiting for the doctor the nurse should never let 
the patient out of her sight. She may prepare what she 
thinks may be needed. Some physicians manage eclamp- 
sia in the so-called conservative method, with elimination 
and sedatives. Others empty the uterus at once. For 
the former there will be required a frame and burner for 
a hot-air bath, hot irons or bricks for a hot pack, the 
necessary oil-cloths and blankets, etc. If an operation 



EDEMA OF LEGS 



85 



is made the nurse must prepare for it in some other room 
unless the patient be sent to a hospital. If labor has 
begun she will, of course, prepare for it as directed in the 
next chapter. 

Frequent Micturition. — Frequent micturition or passing 
of water is a common disturbance of pregnancy. It may 
be due to congestion of 
the bladder or to pressure FlG - 30 



upon the bladder by the 
growing uterus. Fre- 
quent urination during 
early pregnancy, due to 
pelvic congestion, can 
sometimes be relieved by 
the frequent Use of the 
knee-chest position. If 
a woman is troubled at 
night she may get relief 
by sleeping in the Sims 
position or on her face. 
Later in pregnancy fre- 
quent micturition, due to 
the pressure of the large 
uterus, may during the 
day be helped by wearing 
an abdominal bandage. 

Edema of the Legs. — 
Pressure of the enlarged 
uterus upon the return 
vessels from the lower 
extremities may cause 
edema of the legs. This 
should not be mistaken 




for general edema due to Varicose veins of the leg in pregnancy. 

kidney disease. This is 

not serious, and may be relieved by wearing an abdominal 
bandage. If the distention of the legs is considerable 
and troublesome they may be bandaged. 



SO 



PREGNANCY 



Varicosities. — Sometimes the pressure of the uterus 
also causes varicose veins of the legs and vulva. These 
distended veins may become so large and tender as to 
cause much suffering, and they may even burst, causing 
serious hemorrhage. Bandaging is here also the proper 
treatment; sometimes collodion is better for small areas 
or in locations where a bandage is hard to apply. 

Signs of Pregnancy. — All of the physiological and path- 
ological changes of pregnancy are signs of pregnancy. 
They are, however, only probable and not positive or 
certain signs. Cessation of menstruation, for example, 
which is one of the earliest and most important signs, 
may be due to other causes than pregnancy. Its value 
as a diagnostic sign depends much upon the fact whether 
menstruation has been previously regular. Enlargement 
of the uterus may be due to a tumor. Nausea and vomit- 
ing are, of course, not necessarily due to pregnancy. 

The physician or nurse is absolutely certain of the exist- 
ence of pregnancy only when the head, body, and extremi- 
ties of the fetus are felt, when movements are noticed, 
or when the fetal heart is heard. Even the mother cannot 
be trusted in all cases when she says she feels the child. 
Sometimes a woman ceases to menstruate, her abdomen 
gradually enlarges, she feels the movements of the fetus, 
and has in fact all the probable signs of pregnancy and 
so deceives herself and perhaps her physician that she 
makes all preparation for the confinement. At the ex- 
pected time pains may begin and the physician be called 
only to find that the uterus is of normal size and that the 
supposed tumor of pregnancy is only a gaseous distention 
in an hysterical woman. Such cases show the necessity 
of a careful examination before assuming a condition on 
the diagnosis of the patient. 

Abortion. — The termination of pregnancy before the 
child is viable, i. e., before it can live outside of the uterus, 
is called abortion or miscarriage. Premature labor is 
the interruption of pregnancy after the child is viable. It 
is possible that a fetus of twenty-eight weeks may survive. 



ABORTION 



87 



Hence this is the date generally taken to distinguish 
abortion from premature labor. The term abortion is 
sometimes restricted to denote the expulsion of the egg 
before quickening or before the fetal movements are felt, 
i. e., before the sixteenth to the twentieth week, while 
miscarriage applies to the expulsion between the date of 
quickening and the twenty-eighth week. 

The causes of abortion are diseases of the mother or 
diseases of or injuries to the egg. Severe acute diseases, 
like pneumonia, typhoid fever, scarlet fever, etc., very 
frequently cause abortions. Among the chronic diseases 
that result in abortion or premature labor may be men- 
tioned serious heart diseases, kidney diseases, and syphilis. 

Women differ greatly in their liability to abortion. 
Some women can work hard in the house or field, take 
long drives or make journeys, dance or swim, suffer from 
falls or blows without danger, while a slight strain or a 
little unusual exertion will bring on an abortion in others. 
A woman in her first pregnancy does not know her own 
susceptibility, and hence she should be careful to avoid 
all those things that tend to cause trouble. If a woman 
has had one or more abortions she undoubtedly has a 
sensitive uterus which is easily irritated or excited to con- 
tractions. 

The injuries to which the egg may be subjected are 
either accidental or intentional. Accidental injuries are 
such. as may result from falls or severe jars to which the 
mother is subjected. These accidents may cause more 
or less separation of the egg from the uterus, or they may 
even rupture the membranes and thus allow the escape 
of the fruit water. When the egg is intentionally injured 
we have criminal abortion. 

An abortion is said to be complete when the entire 
egg has been expelled from the uterus. It is incomplete 
if part of the egg is retained. The fetus may be expelled, 
but some of the placenta or the membranes may still 
remain in the uterus. In an incomplete abortion there 
is generally hemorrhage and discharge. A threatened 



PREGNANCY 



abortion is a condition where there is danger of expulsion 
of the egg, but where such an expulsion is not inevitable. 
There is present pain, due to uterine contractions, and 
hemorrhage due to some separation of the egg. Both 
symptoms may disappear and the pregnancy continue. 

The treatment of either threatened or incomplete 
abortion is, of course, the function of the physician. 
He should be called immediately. Women are very often 
ignorant of the significance of the signs of threatened 
abortion. Pains are often attributed to disturbances 
of the bowels. It should always be impressed upon a 
patient that any pain of an intermittent character is very 
dangerous and demands instant attention. Any hemor- 
rhage during pregnancy is also of serious import. If the 
nurse is called to a case of threatened abortion before the 
advent of the physician she should first of all keep the 
patient absolutely quiet in bed in the horizontal position. 
If the pains are quite severe and the coming of the 
physician is very long delayed she may even give the 
patient a small dose of morphin. Any discharge which 
occurs should be carefully saved for examination by the 
physician. 

Physicians sometimes treat abortion by packing the 
uterus and vagina with gauze or cotton and subsequently 
removing the packing with the adherent placenta. The 
packing is generally made without anesthesia, but some- 
times this is required. In other cases the contents of the 
uterus are removed with the finger or with a curette after 
preliminary dilatation of the uterus. Here anesthesia is 
nearly always required. The nurse may prepare for the 
operation so far as possible before the coming of the 
physician. 

Extra-uterine Pregnancy. — Pregnancy outside of the 
uterus is one of the most serious pathological conditions. 
It occurs where there is some obstacle in the tube that 
prevents the passage of the fertilized egg into the uterus, 
but which is not sufficiently great to obstruct the passage 
of the spermatozoa outward from the uterus into the 



EXTRA-UTERINE PREGNANCY 89 



tube. The fertilized ovum begins to grow and becomes 
attached to the inside of the Fallopian tube. The thin 
tube wall distends to accommodate the ovum until it 
ruptures or the ovum eats its way through the tube wall. 
A rent is made in the tube which causes a rupture of the 
distended vessels and a very serious hemorrhage occurs. 
The patient may die suddenly of the shock and hemorrhage 
from the rupture of the tube, or the hemorrhage may be 
checked temporarily by the formation of a strong clot. 



Fig. 31 




Double tubal pregnancy, showing rupture of the tube on the right side 
and tubal abortion on the left. 



In a few hours or days this reappears and generally the 
patient dies unless she receives the help of the surgeon, 
who operates and removes the tube. In many cases of 
tubal pregnancy the egg becomes separated from the 
tube and is expelled from its outer end. This is called 
tubal abortion. 

It is a peculiar fact that when pregnancy occurs in a 
tube the mucous membrane of the uterus undergoes some- 
what the same changes as when pregnancy occurs in the 
uterus itself. If contractions in the tube occur or rup- 



90 



PREGNANCY 



ture takes place the uterus also contracts and tends to 
expel this lining membrane, which comes away in pieces 
or sometimes entire in the shape of a cast of the uterus. 
This fact often leads to a mistake in the diagnosis. A 
woman has thought herself pregnant and now has pain 
and some discharge from the uterus. She thinks she is 
having an abortion and the treatment, so far as the nurse 
or the patient is concerned, is the same as in cases of 
abortion. It consists in absolute quiet in bed. If there 
is much shock from the hemorrhage the head must be 
lowered and warm applications applied. The necessity 
for immediate attention is very evident. The nurse 
should never forget the possibility of extra-uterine preg- 
nancy in a case that is apparently an abortion attended 
with symptoms of shock. 

The discharge of blood from the vagina during preg- 
nancy is always a symptom of some serious trouble. 
Besides the two pathological conditions already men- 
tioned, abortion and extra-uterine pregnancy, in which 
this occurs, there are also others equally dangerous. These 
are placenta previa, separation of the normally seated 
placenta, cancer of the cervix, and hydatid mole pregnancy. 

Placenta Previa. — The placenta is normally seated in 
the upper part of the cavity of the uterus and does not 
reach to the internal os. Sometimes, however, it lies 
in the lower segment of the uterus and in front of the 
child, and this condition is called placenta previa. If it 
lies directly over the internal os so that it covers the cervix 
when that is well dilated it is called total or complete 
placenta previa. If it only partially covers the opening 
of the dilated cervix it is called partial placenta previa. 
When the placenta does not cover any of the opening of 
the cervix, but extends only to its margin or border, it 
is called marginal placenta previa. 

The danger of this condition is due to the fact that 
when the cervix begins to dilate in labor under the action 
of the uterine contractions the attachment of the placenta 
to the uterus is more or less broken, and from the dilated 



PLACENTA PREVIA 91 

region bleeding is likely to occur. The detachment and 
consequently the hemorrhage is greater when the placental 
implantation is complete. 



Fig. 32 




Complete placenta previa. (Bumm.) 



It frequently happens that the preparatory pains 
cause sufficient detachment of the placenta to bring on a 
hemorrhage, so that the bleeding may occur before labor 
begins. It may occur any time during the last six months 
of pregnancy. When this is not the case it is often one 



92 



PREGNANCY 



of the first signs of beginning labor. If a nurse should, 
therefore, notice a hemorrhage at the beginning it ought to 
arouse her suspicion of placenta previa and she should 
instantly communicate the fact of the hemorrhage to the 
physician. 

Fig. 33 




Partial placenta previa. (Bumm.) 



The management of placenta previa is, of course, 
the function of the physician. The only thing the nurse 
can do before his arrival is to keep the patient absolutely 
quiet. Anything that might excite or increase the uterine 



PLACENTA PREVIA 



93 



contractions should be avoided. The patient should, 
therefore, remain absolutely quiet in a horizontal posi- 
tion. She must use the bed-pan and under no circum- 
stances get out of bed or even sit up in bed. 



Fig. 34 




Marginal placenta previa. (Bumm.) 



In the meantime the nurse may prepare for the physi- 
cian. He may conclude to tampon the vagina or perform 
some operation. She should have everything in readi- 
ness for him so far as possible. She must have, of course, 



04 



PREGNANCY 



the necessary solutions for disinfection, and it would be 
well for her to have on hand gauze or sterile cotton for 
tampons. She should prepare the operating table and 
the douche. 

It may happen that a nurse may be left with a patient 
who has had one or more slight hemorrhages from 
placenta previa. Ordinarily this complication is a reason 
for the induction of labor. If, however, the child is not 
yet viable and the urgency seems not great and the 
patient is able to keep a competent nurse by her con- 
stantly it may be decided to allow the pregnancy to go 
on for some weeks. When in charge of such a case a 
nurse must fully appreciate her responsibility and be 
ready to act if necessity requires. The directions will, 
of course, be given by the physician in charge. The 
patient, if allowed to be around the house, will be told 
to avoid everything that may bring on uterine contrac- 
tions. She will avoid jars and blows as well as all accidents. 



Fig. 35 




Tamponing vagina in placenta previa. Insertion of retractor. Cotton 
tampons and forceps at hand. 

In case of hemorrhage, however slight, she will, of 
course, go to bed and remain there. When the hemor- 



PLACENTA PREVIA 



95 



rhage is severe the nurse may be required to introduce 
the tampons herself. The technique is as follows : 

The nurse should disinfect her hands as directed in 
the chapter on Labor. The patient should be shaved 
and the genital region thoroughly disinfected. For the 
introduction of the tampons the nurse will require a 
good-sized retractor or a Sims speculum and dressing 
forceps. These, of course, should be boiled. In a sterile 
bowl a 0.5 per cent, carbolic solution should be prepared. 
For the tampons, sterile absorbent cotton is needed. 
It is better to have it prepared in a sterilizer. If not, it 
should be torn from off the roll in pieces, each the size of 
the hand, dipped into the solution, the superfluous fluid 
squeezed out, and then placed on a sterile plate. A dozen 
to twenty of these tampons should be prepared. The 
plate should be placed on a table convenient to the bed. 
With the patient lying in the Sims position the nurse 
inserts the speculum or retractor and pulls back well 
the posterior vaginal wall. Then taking a tampon in the 
dressing forceps she wipes out the blood from the vagina 
and then proceeds to pack in the remaining tampons. 
In this position the uterus falls forward and allows the 
distention of the vagina to its fullest capacity. Two or 
three of the tampons are placed behind the vaginal 
portion of the cervix, another is placed in front, and then 
the remaining tampons are placed over the cervix and 
the entire vaginal canal is filled. When the outlet of the 
vagina is reached the packing should stop. No tampons 
should be placed in the vulva, for they will irritate and 
cause unbearable pressure. 

Separation of Normally Seated Placenta. — This condi- 
tion is due to injury or disease. It is generally attended 
with a discharge of blood. The diagnosis between this 
condition and placenta previa is not easily made. So far 
as the nurse is concerned the treatment consists only 
in keeping the patient quiet in bed and sending for the 
physician, who must assume all responsibility for the 
management of the case. 



or. 



PREGNANCY 



Cancer of the Cervix. — A woman is not likely to become 
pregnant if she has cancer of the cervix in an advanced 
stage. A beginning cancer will develop with great rapidity 
during pregnancy, so that a bloody discharge is apt to 
occur before the end. The diagnosis is easily made by 

Fig. 36 
— . 




Premature separation of normally seated placenta. (Bumm.) 

the physician, but the nurse, without an internal examina- 
tion, can only bear in mind the possibility of this com- 
plication when she has to do with a case of hemorrhage 
during pregnancy. 

Hydatid Mole. — This rare disease is due to a degenera- 
tion of the placental villi. The mole looks somewhat 



HYDATID MOLE 



1)7 



like a bunch of bleached-out grapes of various sizes. 
The embryo or fetus dies and the mole enlarges rapidly. 
It generally begins during the second or third month of 
pregnancy, and before the end of the fifth month the 



Fig. 37 




Hydatid mole. 



uterus is nearly as large as at term. Contractions are 
set up and the uterus begins to expel the mole. Some 
bleeding occurs. With the bloody discharge, pieces of 
the mole are sometimes found and their discovery con- 
firms the diagnosis. The history of the rapid growth 
of the uterus, the absence of fetal movements and heart 
7 



98 



PREGNANCY 



sounds, as well as the softness of the uterine contents, 
also help in the diagnosis, which is established by the 
physician by an internal examination. 

MANAGEMENT OF PREGNANCY. 

While the management of pregnancy is not the function 
of the nurse, still her opportunities for giving good advice 
are so numerous that is is very desirable that she be 
prepared with the elementary principles upon which are 
based the proper hygiene of this condition. 

Diet. — There is a common notion prevalent that a 
woman needs to eat twice as much when she is pregnant 
as when she is not pregnant. The saying is: "She must 
eat for two, herself and her child." This, however, is 
not true. Very little extra food is required to supply 
the needs of the fetus. Moreover a pregnant woman, 
as a rule, takes less exercise, and is less exposed to cold, 
and therefore needs less food for herself. The amount 
of food taken before pregnancy is quite sufficient during 
pregnancy. 

The attempt has frequently been made to modify the 
growth of the fetus by varying the character of the 
food. It has been thought that the development of 
the fetus may be retarded by modifying the mother's 
diet and thus make labor easier. The attempt to keep 
the fetus small by restricting the mother to a starvation 
diet was at one time given a trial, but abandoned on 
account of the suffering thus inflicted on the mother and 
the poor results obtained. Later the attempt was made 
to withdraw the bony matter from the child by keeping the 
mother on a fruit diet. It may be true that the labor 
is easier after such a diet strictly carried out. The child 
is less developed, but the explanation based on the theory 
of the bone salts is absurd. Fruit is not deficient in the 
bone salts, and the considerable quantity of fruit given 
in this diet contains probably quite as much of the bone 
salts as does an ordinary diet. The true explanation of 



MANAGEMENT OF PREGNANCY 



99 



the action of the fruit diet is that is it practically a star- 
vation diet. The amount of nutriment contained in the 
fruit is slight in spite of the considerable quantity eaten. 

The proper diet for a healthy woman during pregnancy 
is the ordinary mixed diet. It is best for the mother and 
for the unborn child. In case digestion is interfered with 
attention must be paid to the choice of food, so as to 
exclude all articles difficult of digestion. Since there is 
generally a slight diminution in digestive capacity it is 
well for the woman to avoid such things as are known to 
remain long in the stomach. For this reason great care 
should be observed in the use of salads, nuts, pork, smoked 
meats, fried meats, and vegetables, as well as pickles, 
etc. Fruits are, as a rule, desirable. Many patients, 
however, find fruit acids harmful to the stomach and 
have to discard nearly all kinds of fruits. 

Special care must be taken with the diet in cases of 
nausea and vomiting of pregnancy. Also in kidney disease 
a strict diet is often prescribed. These are pathological 
conditions and must be treated by the physician. 

A pregnant women often finds it necessary to eat more 
than three times a day. Frequently a light lunch must 
be taken in the forenoon and also in the afternoon, 
and occasionally it is desirable that something should be 
taken at night. In these cases a milk punch is often 
prescribed. 

Bathing. — The functions of the kidney, bowels, and skin 
are intimately related. To a certain extent one can take 
the place of either of the others. We all know that in 
warm weather when perspiration is free the urine is less 
free, and in cold weather when the skin excretion is 
checked the urine is more abundant. In pregnancy the 
care of the skin is of much greater importance than most 
women think. Protection from cold by the wearing of 
warm and loose clothing and the use of frequent baths 
with friction are the measures needed to keep the skin 
in good condition. 

The frequency, duration, and temperature of a bath 



100 



PREGNANCY 



depend somewhat upon the previous habits of the patient. 
If a woman is accustomed to taking a cold plunge every 
morning it is not necessary for her to change this habit, 
provided it does her no harm. If she is warm after the 
bath, if rubbing brings a glow to the skin, the bath is 
probably beneficial. If the previous history indicates 
that the patient has a tendency to abort, cold baths 
should be avoided. It is safer to prohibit all swimming and 
surf bathing, although some women who are accustomed 
to water can continue to swim for several months without 
danger. Frequent cleansing baths in tepid or warm 
water are needed under any circumstances. In the latter 
part of pregnancy it is sometimes difficult for a woman 
to get into a bath tub. In this case, or when she has no 
facilities for taking a tub bath, she must be satisfied with 
a sponge unless she can procure a shower bath. 

Dress. — The dress of a pregnant woman should be 
warm, loose, and light. Underwear of wool, silk and 
wool, or cotton and wool should be worn if the weather 
is at all cool or changeable. A light weight should, of 
course, be chosen in warm weather. The feet should be 
well dressed; fortunately thick-soled, sensible shoes are 
now in style. The chest and abdomen should not be 
constricted by corsets or tight waists. To support the 
skirts, a "corset waist" or any soft waist like a corset 
cover may be worn. For the breasts some find a special 
bust supporter satisfactory. Whatever is worn there 
must be absolutely no constriction about the waist. 
A corset so made that it constricts the waist must be 
laid aside as soon as the diagnosis of pregnancy is estab- 
lished. A proper corset, however, may often be worn 
with advantage through the whole pregnancy. It must 
generally be made to order. Some corset makers now 
understand the principles which should determine a 
maternity corset. It should be as light and soft as pos- 
sible, with no more stays than are necessary to hold it 
in shape. It should be rather long and fit snugly around 
the hips. It should increase in size from below up so 



DRESS IN PREGNANCY 



101 



that the waist is bigger than the hip segment. The chest 
segment that supports the breast must also be perfectly 
loose. Provision must be made for enlarging the middle 
and upper segments as pregnancy progresses. A proper 
corset thus becomes not only a support for the skirts and 



Fig. 38 




Side view of a good maternity corset at about eighth month 
of pregnancy. 

for the breasts, but also serves as an abdominal bandage 
to assist the abdominal walls in withstanding the pressure 
of the enlarged uterus. 

The skirts should be as light as possible. With warm, 
tight-fitting underwear heavy skirts are unnecessary. 



102 



PREGNANCY 



The underskirt as well as the dress skirt must be made 
with folds so that it, from time to time, can be made 
larger about the waist. The outer garment or both 
garments may, with advantage, be made in one piece. 

Attention should also be given to the night-dress. 
A woman often disturbs the circulation of the skin by 
careless dressing at night. If she is obliged to get up 
and pass through a cold hall to a bath-room or water- 
closet she should be provided not only with a warm 
wrapper, but also with warm stockings and slippers. 



Fig. 39 




A good abdominal bandage for use during the latter part of pregnancy. 

If a maternity corset is not worn an abdominal bandage 
will be found of value during the last half of pregnancy. 
It also prevents the overstretching of the abdominal 
walls. A number of good bandages are on the market, 
or a suitable bandage may be made out of strong cotton 
cloth or linen. As a rule no straps under the thighs are 
needed at this time to hold the bandage in place. 

The abdominal bandage is specially useful in cases of 
women who have borne several children and have pen- 
dulous abdomens. It also gives relief from the pressure 
symptoms of edema of the lower extremities, frequent 
micturition, etc. Sometimes violent movements of the 
child cause the woman much distress. Here also the 
bandage gives relief. 



EXERCISE IN PREGNANCY 



103 



Exercise. — It is impossible to lay down a universal 
rule regarding the amount and kind of exercise that 
a pregnant woman should take. Moderate exercise is 
almost always beneficial in that it improves the circula- 
tion of the blood and stimulates the activities of all tissues 
and organs of the body. It improves the appetite, helps 
digestion, and favors the regular movements of the bowels. 
The chief danger of exercise during pregnancy is that if 
excessive in amount or too violent it may bring on con- 
tractions of the uterus, resulting in abortion or premature 
labor. Abortion is much more easily induced in some 
patients than in others. Until a woman knows whether 
she aborts easily or not it is well for her to be rather 
careful in regard to exercise and watchful for the symp- 
toms of trouble. She should not become tired and she 
must watch especially for the symptoms of backache and 
a bearing-down feeling in the pelvis. When she notices 
these symptoms she must at once lie down. If she finds 
that she is able to walk and ride without getting tired 
she will find such exercise beneficial. The danger is not 
generally in moderate daily exercise indoors or outdoors. 
It is rather the unusual exertion that a woman makes in 
an occasional shopping trip or visit, particularly as on 
such a trip she is apt to wear corsets that she has dis- 
carded at home for some weeks. She would better avoid 
dancing at parties or balls. Horseback- or bicycle-riding 
in the early stages of pregnancy is not unusually harmful 
for a good rider if she has studied her own case carefully 
as just described. Such exercise must, however, be under- 
taken only by a person who appreciates its dangers and 
watches its effects carefully. The same may be said of 
the use of the sewing machine. A careful woman may 
use the machine for half an hour at a time without danger; 
but if she should sew for half a day or a whole day at a 
time and become very tired she would be in danger. 
The lifting of heavy weights or straining the body in any 
way may be harmful. It may result in a partial detach- 
ment of the egg. That excessive caution that makes a 



104 



PREGNANCY 



woman afraid to lift her arms above her head is, however, 
unnecessary. 

Toward the end of pregnancy some women find it 
impossible to walk or take other exercise without becom- 
ing very much exhausted. Encouraged by their friends 
to continue they are brought to the verge of despair. 
This is not good. When exercise leads to exhaustion it 
should be given up. As a substitute, massage combined 
with passive movements is valuable. It relieves the 
edema which in these cases generally exists and improves 
the circulation better than exercise. 

Care of the Breasts. — The breasts should be let alone 
until the last month or two of pregnancy. Manipulations 
are unnecessary and may bring on uterine contractions. 
Support should be given with a proper corset or waist. 
During the last six to eight weeks the nipples should be 
well washed with soap and warm water to remove secre- 
tions and then dried thoroughly with a clean towel. 
The secretion sometimes makes a crust which covers the 
nipple. If this is not removed until the nursing begins 
the nipple is found to be very tender and is easily infected. 
The daily cleaning and rubbing of the nipple puts it in 
good condition for nursing. 

Some physicians advise washing the nipple with alcohol 
or some astringent solution to toughen it. Others advise 
the use of lanolin or some other lubricant to soften the 
skin of the nipple. The simple rule given above will be 
found satisfactory. 

Sometimes it is advised to employ methods to develop 
a nipple when it is retracted or deformed. These measures 
are generally unsuccessful. The subject will be further 
discussed when treating of lactation. 



CHAPTER IV. 



LABOR. 

Labor is the expulsion or delivery or birth of the child. 
Confinement is a term that has about the same significance, 
but refers especially to the disability of the mother. 
Likewise, the French term accouchement, i. e., bringing 
to bed, and the English lying-in apply to the mother's 
condition rather than to her active efforts. 

Labor at term is labor occurring about forty weeks 
from the beginning of the last menstruation or when the 
child has reached the normal size and development to 
begin life outside of the uterus. Premature labor is that 
occurring between the twenty-eighth week of pregnancy 
and term. Retarded or delayed labor occurs when preg- 
nancy has lasted more than forty weeks. Sometimes labor 
has occurred three hundred and twenty days after the last 
menstruation. Very rarely labor does not come on at all; 
eventually the child dies and remains in the uterus. This 
is called missed labor. 

Labor in its duration may be normal, slow, rapid, or 
precipitate. It may be spontaneous when it terminates 
without assistance or it may be artificial. 

Eutocia and Dystocia. — In the study of labor we must 
consider the forces, the child or passenger, the passages 
and the mechanism. When all of these are normal we 
have normal labor or eutocia. When any of these are 
pathological we have dystocia. Dystocia may terminate 
spontaneously. Artificial labor is, of course, always 
dystocia. 

Causes of Labor. — Much has been written about the 
factors which set up labor, but nothing is certainly known. 
Some have thought that the nerve centres that control 



106 



LABOR 



the uterine contractions are directly stimulated by toxins 
or poisons of some kind in the blood, while others hold 
that there is reflex action, the peripheral irritation being 
distention of the uterus, changes in the placenta, etc. 

Forces of Labor. — The forces of labor are muscular con- 
tractions. They are of two kinds, involuntary and volun- 
tary. The contractions of the uterine muscle belong to 
the first class and those of the abdominal muscles to 
the second class. The strength of the uterine contractions 
has been measured in various ways. It varies, of course, 
greatly. Normal contractions exert a pressure of from 
about ten pounds to twenty-five pounds per square inch. 
Contractions of less intensity are abnormally weak and 
those of greater intensity are excessive. Practically we 
estimate approximately the strength of the uterine con- 
tractions by noting the degree of hardening of the uterus 
with the hand applied on the abdomen. 

Labor Pains. — The uterine contractions generally cause 
suffering, and hence they are termed pains. The use of 
the word pain often leads to an apparent paradoxical 
expression. A strong or good contraction we call a good 
pain. It does not always happen that the contraction 
causes suffering any more than the contraction of the 
heart or stomach. Some women feel only the pain caused 
by the stretching or tearing of the vulva when the child is 
expelled. They have been almost or entirely unconscious 
of the contractions which opened the uterus and forced 
the child into the pelvis. Suffering is, however, such a 
usual accompaniment of the uterine contractions that we 
commonly speak of them as pains. Uterine contractions 
or pains occur at more or less regular intervals, separated 
by periods of rest. The contraction begins slowly and 
is perhaps not felt by the patient. The hand placed on 
the abdomen over the uterus notices a hardening of that 
body. It becomes shorter and thicker. If the woman 
is lying on her back the uterus rests against the back- 
bone and projects more prominently toward the front. 
As the contraction increases in intensity it becomes more 



STAGES OF LABOR 



107 



painful. The uterus is felt through the abdominal wall 
almost as hard as a stone. After reaching the climax 
the contraction gradually disappears. By keeping the 
hand over the uterus and noting exactly the time of the 
beginning and the end of the contraction we notice that 
it lasts longer than the pain which the woman feels. A 
good contraction lasts from a minute and a half to two 
minutes. The pain is felt by the mother perhaps a minute. 

Pregnancy Pains. — We may often observe uterine con- 
tractions during pregnancy. A cold hand placed on the 
abdomen over the uterus will often cause it to harden. 
During the last three or four weeks of pregnancy, spon- 
taneous contractions at irregular intervals are the rule. 
They may occur every hour or two or they may occur 
several times in one day and not at all the next. They 
are sometimes noticed by the patient, but frequently 
cause her no suffering and are entirely unobserved by 
her. These pains occurring during pregnancy are often 
called preparatory or false pains. They obliterate the 
cervix and probably sometimes force the head of the 
child into the pelvis. 

Stages of Labor. — Labor begins when the contractions 
occur with considerable regularity and continue until, 
in normal cases, the child is born. Labor is generally 
divided into three stages: In the first or opening stage 
the mouth of the uterus is dilated until there is almost 
no separation between the uterus and the vagina; they 
form one canal (Fig. 40) . In the second stage the child is 
expelled from the body. In the third stage the after- 
birth is expelled. 

First Stage of Labor. — In the first stage the pains are 
called opening or dilating pains. Only the contractions 
of the uterine muscles are here of value. The mother 
has little or no tendency to help with the abdominal 
muscles, i. e., to bear down. Sometimes an ignorant 
nurse will encourage her to bear down. Such advice is 
unwise. The abdominal muscles can help but little, 
and the mother unnecessarily exhausts her strength. 



108 



LABOR 



As hasjbeen said, the contractions are not always felt. 
With the first child there is considerable suffering, and 
there need never be fear of the lack of warning. In 
subsequent labors, however, it is often important that 
the patient should be informed that she may not feel the 
first pains much. Without this warning she may be too 
late in calling the nurse and physician. A woman who 



Fig. 40 




Effacement and dilatation of the cervix. 



has easy labors should be instructed to watch closely for 
the uterine contractions when the time of her expected 
confinement arrives. She must report if she feels uncom- 
fortable. The nurse, if she be present, can determine 
whether the discomfort is due to the beginning of labor 
or not by watching for the uterine contractions by placing 
her hand on the abdomen. 
At the beginning of labor, pains occur every ten to 



BAG OF WATERS 



109 



thirty minutes. As labor progresses they generally 
increase in frequency and in intensity. They may or 
may not cause pain in the back. 

The first stage of labor may last from two or three 
hours to several days. In women who have never borne 
children it is generally longer than in those who have 
had children. With the first labor this stage lasts on an 
average fourteen to sixteen hours. In women who have 
had children it lasts from six to eight hours. Its apparent 
shortness in some cases is due, as just said, to the impos- 
sibility of ascertaining exactly when it begins. 

Effacement of the Cervix. — The system of muscle fibers 
of the uterus is so constructed that when they contract 
they tend to pull open the internal os. The fibers of 
this region are, so to say, gradually pulled up into the 
lower segment of the body. The cervix becomes more 
and more funnel-shaped as the internal os is gradually 
opened. Eventually the projecting cervix disappears 
as the cervical canal becomes a part of the cavity of the 
uterus, forming a part at least of its lower segment. We 
say that the cervix is effaced or obliterated. Sometimes 
this effacement is effected by the preparatory contrac- 
tions of pregnancy. When it is completed the dilatation 
of the external os begins (Fig. 40). 

Formation of the Bag of Waters. — During the effacement 
of the cervix the wall of the lower segment of the uterus 
is more or less separated from the membranes which 
enclose the fruit and its waters. This causes a slight 
"show," which is one of the first signs of the beginning 
of labor. It also results in the formation of the bag of 
waters. This consists of the free or separated portion of 
the membrane which projects into the funnel-like canal 
and later into or through the dilating os when distended 
by the uterine contractions. The distention disappears 
during the interval. The water which fills the bag is 
called the forewater, and is that portion that lies in front 
of the head. During a contraction the head is pressed 
against the side wall and like a valve cuts off the fore- 



110 



LABOR 



water from the rest of the fruit water. The bag during a 
pain may be hemispherical, glove-shaped, or pyriform. 



Fig. 41 




Formation of the bag of waters with the forewater. The eff acement and 
dilatation of the cervix separates it from the overlying membranes which 
project into the cervical opening as a pouch or bag and contain the 
forewater. 



The contained fluid transmits the pressure equally in all 
directions and hence the bag is very valuable in the 
dilatation of the cervix. 



SECOND STAGE OF LABOR 



111 



Rupture of the Membranes. — The rupture of the mem- 
branes, or the bag of waters, may occur at any time during 
labor. It sometimes happens hours or even days before 
labor begins. When it occurs before the beginning of 
labor the fruit water may drain away and we may have 
what is called a dry labor. In such a case the woman 
should remain in bed to prevent unnecessary loss of the 
liquor amnii. If the bag of waters breaks before the end 
of the first stage of labor there is said to be a premature 
rupture of the membranes. If the membranes are very 
tough they may not rupture when the uterus is opened. 
Sometimes the head reaches the vaginal outlet before 
the membranes rupture, and it may be necessary for the 
physician to artificially tear open the bag in order to 
allow the escape of the child's head. A tardy rupture of 
the membranes delays labor. In absolutely typical cases 
the membranes should rupture at the end of the first stage 
of labor. 

Second Stage of Labor. — The pains during the second 
stage of labor are called expelling or bearing-down pains. 
Here both the contractions of the uterus and of all of 
the abdominal muscles are brought into play. It is not 
necessary that the mother be instructed to bear down; 
she does it unconsciously. As the head is forced through 
the pelvis and approaches the outlet the vulva begins to 
open. The dilatation of the vaginal outlet causes a peculiar 
tearing pain. The cry of the woman is quite different 
from that in the early stage of labor. An experienced 
nurse or physician can often tell the stage of labor by 
the nature of the patient's cry. 

The second stage of labor lasts from a few minutes 
to several hours. It is two or three hours long on the 
average in women who have never borne children, and 
in subsequent pregnancies the average is perhaps one to 
two hours. 

One can determine the exact moment of the complete 
dilatation of the uterus only by making an internal 
examination. For the physician this is often undesirable, 



112 



LABOR 



and for the nurse such an examination is very seldom 
allowed. While it is not necessary to determine this 
moment with so great accuracy, it is, however, desirable 
to know approximately the stage or progress of labor. 
If a nurse is alone with the patient she wishes to be able 
to inform the physician concerning its progress. This she 
can do by observing the character of the pain and noticing 
when the bearing-down pains begin. The rupture of 
the bag of waters is also noted and reported. By external 
examination she can find out whether the head has entirely 
entered the pelvis, and by pressing with the fingers behind 
the anus on each side of the sacrum she can tell whether 
the head is approaching the outlet. 

Third Stage of Labor. — The third stage of labor may 
last from a few minutes to many hours. The greater 
part of the after-birth is often expelled from the body of 
the uterus into the cervix and vagina, where it remains 
held by the membranes which are not wholly detached. 
This partial retention of the placenta accounts for many 
cases of prolonged third stage of labor. Sometimes, 
however, the placenta is quite firmly attached to the 
uterus or the uterine contractions are too weak, and the 
third stage would be much prolonged if the spontaneous 
expulsion of the after-birth were waited for. In these 
cases labor is often completed by expressing or squeezing 
out the placenta with the hand so that the third stage 
is rarely allowed to last longer than two hours. The 
pains of the third stage are called after-birth pains. The 
uterine contractions differ considerably from those that 
occur in the earlier stages of labor. They are much longer 
and the resting intervals are shorter. A change is grad- 
ually taking place in the muscles of the uterus by which 
it becomes a hard, firmly contracted body. 

After-pains. — After the completion of labor by the 
expulsion of the placenta the uterine muscle passes into 
a state of permanent contraction. This contraction 
causes no suffering. It occasionally happens, however, 
on account of the presence of blood-clots or pieces of 



MECHANISM OF LABOR 



113 



retained decidua which act as foreign bodies that the 
uterus is excited to renewed contraction. These are 
painful and have received the name of after-pains. They 
may occur at regular intervals and may last for three or 
four days. Anything which stimulates the contraction 
of the uterus may cause these pains : for example, knead- 
ing the surface of the abdomen with the hand or the 
application of the child to the breast. They may occur 
after the birth of the first child, but are more likely to 
be present after subsequent labors. 

It will be seen that we have five kinds of uterine pains: 
There are the preparatory or false pains which occur 
during pregnancy. Then during labor there are the 
opening pains in the first stage and expelling or bearing- 
down pains in the second stage and the after-birth pains 
in the third stage. Then finally in child-bed there are 
the after-pains. 

MECHANISM OF LABOR. 

By this term we understand the results of the action 
of the forces of labor applied in expelling the fruit from 
the uterus. Very briefly we describe the progress of the 
child through the obstetrical canal. 

Posture. — Introductory to this description, however, 
we must define a few terms in common use. By the 
posture or attitude of the fetus we understand the relation 
of the various parts of its body to each other, i. e., how 
the fingers are held, how the hand lies in relation to the 
forearm, how the forearm lies in relation to the arm, the 
arm to the body, etc. The normal posture or attitude 
of the fetus in the uterus is that of flexion. The head 
is somewhat flexed on the neck and the neck on the body. 
The body is bent on itself. The thighs are flexed against 
the body, the legs on the thighs, the feet on the legs. 
The arms are applied to the body. The forearm is flexed 
on the arm and the hand flexed on the forearm. In this 
attitude the child occupies the smallest possible space. 
8 



114 



LABOR 



It is the natural posture for a child to lie in when enclosed 
in a cavity of limited size. Sometimes, however, a devia- 
tion from this flexion attitude is found. It may be called 
a partial extension attitude. The head is extended on the 

Fig. 42 




Sagittal section through the pelvis and uterus near the end of the first 
stage of labor, showing the posture of the child and also the bag of 
waters intact (A). (Bumm.) 

body and the back bent backward instead of forward. 
This is the posture of the child in cases where the face 
presents instead of the top or back of the head. The 
posture of the child varies during its passage through 
the obstetrical canal. 



POSITION, PRESENTATION, AND STATION 115 

Position. — By position of the child we denote its rela- 
tion to the uterus. If the head presents, the position of 
the child is expressed by saying that it lies with its back 
to the left or to the right, to the left anterior or to the 
right posterior, etc. Frequently also we denote position 
by using the back of the head or occiput as the determin- 
ing point. Thus we say the position is occiput left anterior 
(o. 1. a.) or occiput left posterior (o. 1. p.), etc. The 
position varies also during the passage of the child. 

Presentation.- — By the presentation we mean that part 
of the child that precedes in its progress through the 
obstetrical canal or the part that is first felt when a 
vaginal examination is made. Thus we may have a 
head, a breech, a foot, an arm, a shoulder presentation, 
etc. Normally the head usually presents. Under head 
presentation we may also have the face and brow presenta- 
tion when the child lies in an attitude of extension. In 
a typical labor some part of the skull presents. We dis- 
tinguish here the vertex, the occiput, the fontanelle, etc. 
The presentation depends upon the attitude of the child. 
If the presenting head is well flexed the presentation is 
occiput. If the head is well extended the presentation 
is face. The position is independent of the posture or 
presentation. The position may be o. 1. a. whether the 
attitude be one of flexion or extension. 

Station. — The head may be located in the inlet of the 
pelvis or above the inlet, in its excavation or in its outlet. 
The term station is used to denote the location or situation 
of the head or presenting part. 

In our description of the mechanism of labor we shall 
describe first in some detail the progress of the typical 
head presentations. These comprise over nine-tenths 
of all cases of labor, and it is desirable that the nurse 
should understand them, for she is liable to be alone 
with the patient during a normal labor. In cases of 
abnormal presentation labor is usually much delayed and 
the nurse will be able to call the physician who will assume 
responsibility for the management. The nurse should 



116 



LABOR 



be able to determine by external examination the presen- 
tation, position, and posture of the child, but she is not 
expected to conduct the labor in abnormal cases, and 
hence needs to understand its mechanism only so far as 
may be necessary to recognize deviation from normal. 



Fig. 43 




Diagram showing the status of fetus and pelvis at the beginning of 
labor. The presentation is vertex (flexion has not begun) : position, 
occiput left (o. f.) ; station, above inlet. 

Three kinds of movements of the fetus occur, namely, 
translation or movement of the fetus along the canal, 
flexion or movement on a transverse axis, and rotation 
or movement about a longitudinal axis. The progress 
may be described in four steps: 

Descent. — The first step is the descent of the head into 
the pelvis. As has been said, this may begin during the 
last weeks of pregnancy if the opening into the pelvis is 
large as compared with the child's head and if the lower 
segment of the uterus becomes relaxed. By observing 



DESCENT 



117 



the shape of the inlet it will be seen that its cross- 
diameter is longer than its anteroposterior-diameter. It 

Fig. 44 




Status during first step in the mechanism of labor. Descent has 
begun, accompanied by flexion. Presentation, posterior vertex; posi- 
tion, occiput left; station in inlet. 

Fig. 45 




Sagittal section showing same progress in the mechanism of labor as 
Fig. 44. 



118 



LABOR 



will also be observed that the anteroposterior diameter 
of the child's head, i. e., the occipital frontal diameter, 

Fig. 46 




Status during second step in the mechanism of labor, i. e., rotation 
has occurred. The presentation is posterior vertex; position, occiput left 
anterior (o. 1. a.) ; station, head in excavation. 

Fig. 47 




Status at the end of descent and rotation. Presentation is vertex; 
position, occiput anterior (o. a.) ; station, head in outlet. 




Fetal skull, showing displacement of bones in molding as in Fig. 51. The 
parietal bones project over both the frontal and occipital. (Bumm.) 



120 



LABOR 



is larger than the transverse diameter. It is therefore 
evident that when the head descends into the pelvis 
its long diameter, which must coincide with the long 
diameter of the pelvis, must lie more or less trans- 
verse, i. e., the occiput must point to one side or the 
other of the pelvis. When the head has passed into the 

Fig. 50 




Molding of fetal head during labor. Bone displacements shown in 
Fig. 48. Caput succedaneum also shown. (Bumm.) 

pelvis so far that its greatest circumference has passed 
through the inlet it is said to have descended or entered 
the pelvis (Fig. 46). Its station is in the excavation. 
During this step some flexion of the head may take place. 
(Fig. 44). Some of the head begins so that it fits the 
passage (Figs. 50 and 51). Likewise a swelling of the 
presenting part of the head may occur. This is called 
the caput succedaneum (Fig. 50). 



ROTATION 



121 



Rotation. — The next step in labor is the rotation of 
the head. While the transverse diameter of the inlet is 
longest, at the outlet the anteroposterior diameter is 
longest. Hence it is evident that the head which descends 
with its long diameter crosswise must now rotate so as 
to bring that diameter into the anteroposterior diameter 
of the pelvis in order that its expulsion may take place 
most advantageously. If the rotation occurs normally 



Fig. 51 




Molding of fetal head during labor. Displacements of bones shown 
in Fig. 49. (Bumm.) 

the back of the head or occiput is brought to the front; 
sometimes an abnormal rotation occurs by which the fore- 
head is brought to the front or the occiput posterior. 
This is a great disadvantage, for it makes the expulsion 
of the head much more difficult. The rotation occurs 
within the cavity of the pelvis and usually in the early 
part of the second stage of labor. 

Exit of Head. — The third step in the mechanism of 
labor is the exit or expulsion of the head, which occurs 



122 



LABOR 



with its extension. After the rotation of the head in the 
pelvis the presenting part, i. e., the occiput, is gradually 
forced through the vulva and appears close under the 



Fig. 52 




Sagittal section showing the beginning of the third step in the mechanism 
of labor or the exit of the head. (Compare Figs. 47 and 54.) 



Fig. 53 




End of the third step in the mechanism of labor, i. e., the exit of the head. 
(Compare Fig. 55.) 



EXPULSION OF HEAD 



123 



symphysis. When the pain stops the head recedes into 
the pelvis to appear again at the next contraction. Even 
before the head is visible in the vulva it can be felt by 
pressing with the fingers each side the end of the sacrum. 
By observing the perineum during the pain it is seen to 
distend. As soon as the vulva begins to open and a trace of 

Fig. 54 




Beginning of the third step in the mechanism of labor, i. e., exit of the 
head. The perineum is distended and the head visible. (Bumm.) 



the head can be seen we say the head is visible. When the 
head advances so far during a pain that it does not recede 
into the pelvis in the interval we say that it has escaped 
from the bony pelvis. The vulva dilates more and more 
with each pain. The occiput projects more and more 
out of the pelvis. If the patient is lying on her back the 
presenting part which first pointed in the horizontal 



124 



LABOR 



direction is now directed more and more upward. When 
the presenting part has passed from under the symphysis, 
so that the region below the occiput, i. e., the subocciput, 
is applied to the symphysis, the condition is favorable 
for the birth of the head. More and more of the head 
appears, the vulvar ring stretches, and finally slips over 
the forehead and over the face when the head is born. 
You will observe from this description and from the accom- 
panying figures that this expulsion of the head is accom- 
panied by an extension. Hence this process is also called 
extension. 

Fig. 55 




The head is about to pass through the vulvar ring in the suboccipito- 
frontal circumference. (Bumm.) 



Exit of the Body. — The final stage in the mechanism 
of labor is that of expulsion of the body. While the shoul- 
ders pass more or less closely through the transverse 



EXIT OF BODY 



125 



diameter of the inlet, i. e., generally with the back of 
the child toward the abdomen of the mother, in the pelvis 
they rotate back again and are delivered with the back 
to one side. Sometimes the anterior shoulder comes 
out first under the symphysis, when the posterior shoulder 
follows over the perineum, while at other times the pos- 
terior shoulder is delivered first. After the birth of the 
shoulders the rest of the body slips out without any 
further trouble. 

Fig. 56 




Exit of the body. The anterior shoulder is escaping first. Notice that 
the head is only supported by the hand; no traction is made. 



Expulsion of the Placenta. — The methods of the separation 
and expulsion of the after-birth, i. e.,t\\e placenta and mem- 
branes, are illustrated by the two accompanying figures. 
One is called the Schultze method, because it was first 
described by Prof. Schultze, the celebrated obstetrician and 
teacher of Jena, Germany. The other method was de- 
scribed by Duncan, a famous obstetrician of England, and 
so is called the Duncan method. According to Schultze 
the placenta begins to separate from the uterus in the 



126 



LABOR 



middle. Blood collects in the space between the placenta 
and the uterine walls. This grows larger and larger as 
the separation continues until the placenta is fastened only 
by a rim at the attached border, or perhaps only by the 
attached membranes. At this stage the placenta is lying 
in the lower segment of the uterus. Finally the last 
adhesions to the uterus are severed and the mass is ex- 
pelled from the body with the membranes and fetal jside 



Fig. 57 




Separation of the placenta by the Schultze method. 



of the placenta on the outside, and the blood that was 
behind the placenta contained on the inside of the bag as 
it is now turned inside out. According to the Duncan 
mechanism the placenta begins to separate from the 
uterus at its lower edge. As the separation continues 
it is gradually expelled from the uterus with its uterine 
surface foremost, in which way it appears at the vulvar 
outlet. Both methods of expulsion are normal and occur 
with about equal frequency. By the Schultze mechanism 



MANAGEMENT OF LABOR 



127 



there is generally no hemorrhage until after the placenta 
is expelled, when a large clot or quantity of blood comes 
in or with the after-birth. By the Duncan mechanism 
there is apt to be some hemorrhage during the process 
of expulsion. 

Fig. 58 




Separation of the placenta by the Duncan method. 



MANAGEMENT OF LABOR. 

It is the duty of the nurse who is assisting in a case 
of labor to avoid infecting the patient herself, to prepare 
the patient and her bed so that she may not become 
accidentally infected, to prepare for all possible emer- 
gencies and to assist the patient as far as possible during 
labor. Certain general directions concerning the nurse's 
duties have been already given in the first chapter. If 
the nurse is not in the house when labor begins she 
has, as a matter of course, visited her patient and made 
herself familiar with the management of the house, 
and knows where to find the bedding and the patient's 



128 



LABOR 



outfit. She has with her those things that are absolutely 
necessary for disinfection and for use about the patient 
in case of need in an emergency. 

Nurse's Outfit. — The following articles make a fair 
outfit for the nurse : 
Nail brush. 

Tube or bottle of clean or antiseptic soap. 

Nail file. 

Scissors. 

Glass or soft rubber catheter. 
Glass douche point. 

Bottle of sublimate tablets (7 grains each). 

Tape or ligature. 

Aspirating catheter. 

Hypodermic syringe. 

Two fever thermometers. 

Phonendoscope. 

Rubber gloves. 

Large gown. 

Patient's Outfit. — Sometimes the patient purchases 
the supplies for dressings in 'bulk and the nurse prepares 
them. If sterile gauze and cotton are used and the nurse 
prepares the dressings antiseptieally, subsequent sterili- 
zation is unnecessary. In most towns as well as cities 
there are, however, large hospital sterilizers where dress- 
ings, sheets, towels, and gowns can be sterilized, and it 
is in general more satisfactory to have the patient send 
her sheets to be sterilized with the dressings and then 
kept untouched ready for use. 

Under any circumstances the patient needs bowls, 
pitchers, etc., with certain druggist's supplies. Such a 
list should include the following articles: 

One rubber or enamel three-quart fountain syringe. 

One enamel combination douche-pan or bed-pan. 

Two or three enamel or china bowls. 

Two or three enamel or china pitchers. 

One bath thermometer. 

Two large nail or hand brushes. 



PATIENT'S OUTFIT 



129 



One nail file. 

One bottle (25) sublimate tablets (7 grains each). 
Three ounces of lysol. 
One pint of alcohol. 

Two hundred and fifty grams of ether. 

One tube or bottle of antiseptic soap. 

One ounce of fluidextract of ergot (or some other 
preparation for hypodermic use may be substituted for 
the U. S. P. fluidextract). 

Three ounces of olive oil for baby. 

Rubber sheeting, three yards (one and one-half 
yards wide). This is cut so as to make two pieces, one, 
one and one-half by one and three-quarters yards, to 
cover the mattress, and one, one and one-half by one and 
one-fourth yards, to serve as a rubber draw sheet or 
drainage sheet. 

If the nurse makes the dressings she will need the 
following additional supplies: 

Twenty-five yards of sterile gauze. 

Four pounds of absorbent cotton. 

Four yards of strong cotton cloth for bandages. 

In addition the patient should have properly laundered 
and put away for use during and following the confine- 
ment: 

One dozen sheets. 

One and one-half dozen towels. 

Three pillow-cases. 

Three night-gowns. 

Three pairs long stockings. 

One dressing gown or bath robe. 

When the dressings are prepared and sterilized in the 
hospital the following list makes a satisfactory outfit: 

Three packages of vulvar dressings, one dozen in each 
package (each dressing 18 x 8, taking gauze 12 x 36 and 
cotton filling 12 x 7, full thickness). 

Twelve yards of gauze and three pounds of cotton. 

One package of perineal gauze sponges, each 9x9, 
four thicknesses (six yards of gauze). 
9 



130 



LABOR 



Two packages cotton sponges, twenty-five in each (one 
pound of cotton). 

One pound of sterilized cotton. 

Five yards of sterile gauze in one-yard lengths. 

Two packages of bed-pads, one in each, 24 x 24, two 
thicknesses of cotton. 

One pair of leggings. 

Six breast bandages, 12 x 48. 

Four abdominal bandages, 18 x 48. 

Ligature of No. 8 silk, twenty-eight inches long, in 
envelope. 

Two four-ounce bottles of sterile soap. 
One nail file, one bath thermometer, one douche point, 
all sterile. 

Two sterile nail brushes. 

The outfits described cost from $10 to $15. A poor 
patient can save considerable by using white oil-cloth 
instead of rubber sheeting, and she may get along with 
two pounds of cotton, and she may dispense with lysol 
and ether. She may use' a syringe and bowls, pitchers 
and douche-pan that are already in the house, or she can 
borrow, for these can be sterilized by boiling before using. 

Preparation of Self. — In order to avoid any danger of 
infecting the patient, the nurse should be as nearly 
clean as possible. She must be free from suspicion of 
any contagious disease. If she herself has had measles, 
scarlet fever, whooping cough, mumps, erysipelas, or any 
other contagious disease she must not go to a case of 
obstetrics for at least a month after recovery, during 
which convalescence she must have taken numerous 
cleansing baths. Colds and la grippe are also contagious; 
it is certainly not desirable that an obstetrical nurse 
should be suffering from a severe cold. There is always 
danger that she will be the means of conveying it to the 
mother or child. If she has unfortunately contracted 
such a cold a few days before the expected confinement 
she should use all measures to cure herself, including 
gargles and spraying of the throat and nose. 



PREPARATION FOR LABOR 



131 



If she has been in attendance on a case of contagious 
disease she should not go to an obstetrical case for a week, 
during which time she should bathe frequently, and 
particularly wash the hair. If a quicker preparation is 
absolutely necessary, she should take a Turkish bath 
and wash the hair with utmost thoroughness. If she is 
very conscientious it may be possible for her to disinfect 
herself in a day. 

When labor begins the nurse should put on clean wash 
clothes. It is well known that of all sources of danger 
the hands are much the greatest. It is not possible for 
a nurse to keep her hands sterile. During the labor she 
is obliged to handle so many things about the room that 
she is constantly contaminating her hands. Unless she 
is conducting a labor herself, and needs to touch the 
genitals of the patient, it is not necessary that she be 
absolutely sterile. When she is preparing the dressings 
or touching the patient she should be so clean that there 
is no danger of contamination. For this purpose it is 
better that she put on gloves. At all times, however, 
she must be sure that her hands are not contaminated 
with dangerous germs, i. e., pus germs or those of 
erysipelas. For this reason it is proper that she should 
clean her hands as well as she can with soap and water 
before giving the patient her enema and bath, and 
then sterilize them before preparing the patient for 
her examination. If she has thoroughly disinfected her 
hands at the beginning of labor and washed them fre- 
quently during the labor, especially when they become 
contaminated, she is doing her duty. If in the absence 
of the physician it is necessary that she should deliver 
the patient herself, she must, of course, see to it that her 
hands remain sterile and also wear gloves. 

It is well known that the skin, even when ordinarily 
clean, is contaminated with innumerable bacteria. If 
an abrasion or other wound is made these bacteria 
cause an infection which results in an inflammation of 
greater or less extent, and perhaps in the formation of 



132 



LABOR 



pus. While these germs are all over the surface of the 
body they are found in much greater numbers in some 
places than in others. About the hand they are found 
especially between the fingers and around the nails. If 
a person wears rings, they are found also in numerous 
quantities under the rings. A nurse should never wear 
rings. 

The germs we especially fear are the ordinary pus 
germs, the germs of erysipelas and bacteria that are found 
in the feces, and the ordinary germs of decomposition. 

While nine-tenths or more of the germs can be removed 
by the proper use of soap and hot water, yet some remain, 
and they must be destroyed or gotten rid of by certain 
chemical substances which we call antiseptics. The 
method of cleaning the hands is as follows: 

Method of Cleaning the Hands. — First scrub the hands 
and arms with clean soap and hot water, using a clean 
brush, for ten minutes. The water should be as hot as 
can be borne. The soap must be clean. A cake of dirty 
soap, perhaps with numerous cracks, which is lying around 
the common house sink and has been used by everyone 
for weeks, is dangerous. The hands could even become 
contaminated by the use of such soap. A clean cake of any 
good soap will do. The soft or green soap which contains 
a small amount of antiseptics, put up in collapsible tubes, 
is a very convenient and safe form to use. It may also 
be kept in small bottles. The brush must also be clean. 
A brush that has been used to clean an infected hand is 
positively dangerous. Pus germs may live for days or 
weeks in its fibers. It is easily seen how these may be 
rubbed into the fingers and cause a serious contamina- 
tion. Unless the brush is known to be clean it should be 
boiled before using. In scrubbing the hands it is impor- 
tant to separate and wash carefully between the fingers. 
The region of the nails is much the most dangerous, 
and about nine-tenths ,of the whole time consumed in 
cleaning the hands should be spent in cleaning around 
the nails. During the washing the water should be 



CLEANING THE HANDS 



133 



frequently changed. It is better to use running water. 
If a bowl of water is used the water should be renewed at 
least three or four times. The dirt removed at the first 
washing remains in the water, and would easily cause a 
renewed contamination of a clean hand. 

Next comes the cleaning of the nails with a clean nail 
file. A nail file that has been contaminated by use on a 
contaminated hand would be one of the most dangerous 
things to use. A suspected file can always be cleaned by 
boiling thoroughly. From three to five minutes at least 
are required to clean the nails. The best way to deter- 
mine whether the nails are clean or not is to look at them 
in a good light with a conscientious eye. If any particles 
of dirt, no matter how minute, are seen around the nail, 
or on the ridge at the side of the nail, one may be certain 
that the cleaning is not complete. If particles of dirt 
large enough to be seen are present, we may be sure that 
bacteria which are microscopic are not removed. 

After the use of the nail file the hands should be scrubbed 
again with soap and hot water for from two to five min- 
utes, to remove all matter loosened by the file. These 
steps in the disinfection have consumed from fifteen to 
twenty minutes. 

The hands and arms should now be dried with a clean 
towel and then scrubbed with 70 per cent, to 80 per cent, 
alcohol for from three to five minutes. The alcohol can 
be used in a small clean bowl like an eating bowl or a 
finger bowl. As said before, the nails are, of course, the 
parts of the hand that receive the most attention. 

Now comes the chemical disinfection. We may use a 
sublimate solution of a strength of 1 to 500 to 1 to 2000, 
or carbolic acid 2 to 3 per cent., or lysol 2 per cent. Such 
a solution is contained in an earthenware or enamelware 
bowl. The hands and arms are thoroughly scrubbed 
in this solution for from three to five minutes. 

The entire disinfection by this process requires from 
twenty to thirty minutes. After the hands are once 
thoroughly cleaned the later sterilization requires much 



134 



LABOR 



less time. If the hands have been badly contaminated, 
for example, in dressing a case of erysipelas or caring for 
a person with puerperal fever the disinfection will take 
much longer. It is impossible to disinfect the hands at 
one time in such a case. Here it is necessary to repeat 
the process three or four times at intervals of two or 
three hours. 

If there are on the hands or arms inflamed sores they 
must after the disinfection be covered with collodion. 
Any pustules, no matter how small, must be evacuated, 
cleaned thoroughly with alcohol, and then sealed with 
collodion. If such a collodion dressing cannot be kept on 
the hand, or if there is any doubt as to its furnishing a 
sufficient protection, the hand should be protected by 
rubber gloves. If a nurse has any such sores on the hands 
she should call the attention of the physician to them and 
ask his advice as to their proper care. In this way only 
can she feel that she is doing her duty and also protect 
herself against the possible serious charge of infecting the 
patient. 

Preparation of Patient. — Begin (hiring Pregnancy. — The 
preparation of the patient may well begin a week or more 
before her expected confinement. A thorough, daily 
bath to keep the skin in good condition, laxatives and 
injections, if necessary, to empty out the large bowel, 
make not only the labor itself safer but also the child-bed 
more normal. The patient's hair should also be washed. 
If the nurse is in attendance before the confinement she 
will supervise this preparatory treatment. 

Enema. — When real labor first begins the nurse should 
give the patient an enema and then a bath. The enema 
should under no circumstances be omitted unless the 
labor is too far advanced. Often the patient will assure 
the nurse that her bowel is empty, that she has had three 
or four passages. The enema must be given to wash out 
the rectum, which still retains some fecal matter in spite 
of the bowel movements. If the head is down on the peri- 
neum of course it will be impossible to introduce much 



PREPARATION OF PATIENT 



135 



water into the rectum, and there will be no time for the 
enema, which must therefore be omitted. 

Use of Closet — Shall the patient use the water-closet 
after taking the injection and during the progress of 
labor? There are two or three objections to the use of 
the water-closet. The closet seat is not clean and the 
patient's skin becomes contaminated; after the cleaning 
of the patient, therefore, she should not sit on the closet. 
If she should by chance use the closet she should be 
thoroughly washed before getting back into her pre- 
pared, sterile bed. Foul gases frequently come from 
the closet basin. These may result from poor plumbing, 
which allow the sewer gases to ascend. They may also 
be due to the fact that the basin is not thoroughly clean. 
It is indeed a very difficult matter to thoroughly clean 
both the basin and its outlet down to the trap. When 
a woman sits on a closet these gases ascend and contami- 
nate not only the external genitals but also perhaps 
the vagina itself. Later in the labor there is also the 
danger of the expulsion of the child during the act of 
defecation. A woman frequently mistakes the straining 
caused by the descending child for a call to stool. If she 
goes to the closet it is possible that the child may be 
expelled and even fall into the closet basin. Such acci- 
dents have more than once occurred. For these reasons 
it is safer for a patient to use the chamber-pot. If a patient 
use the closet after the first enema the nurse should see 
that the seat is thoroughly cleaned. Later in the labor 
she had better always make use of the pot or the bed- 
pan. 

Bath. — After the enema a thorough cleansing bath 
should be given. If time permits and the facilities are at 
hand a tub bath or a shower bath should be used. Other- 
wise a sponge bath is given. The objection to the tub 
bath is that the water becomes contaminated with the 
dirt from the body. The water comes in contact with 
the vulva or may enter the vagina. The danger, especially 
with clean patients, is slight. Nevertheless, a shower 



136 



LABOR 



bath is equally cleansing and does not subject the patient 
to that risk. 

After the bath the patient is dressed in clean clothes, 
lies on her bed protected by a clean sheet, or sits in a 
chair while her hair is cared for. It is to be combed, 
braided, and securely tied so that it cannot come undone 
during the labor. 

Dress. — The dressing of the patient during her labor 
must now receive our attention. If she is to remain in 
bed all of the time a short gown or shirt is sufficient. A 
clean undershirt with sleeves answers every purpose and 
is perhaps better than a cotton or linen garment. A long 
night-dress may also be used, but it is more in the way 
and becomes soiled by discharges, and needs to be changed 
several times during a labor of ten or fifteen hours. A long 
night-gown may be worn if an obstetric gown has not 
been prepared. Clean stockings may be worn if the feet 
are cold or if for any other reason they are desired. If it 
is not necessary for the patient to remain in bed during 
the whole labor a long night-gown should be put on over 
the short obstetrical gown and over this the ordinary 
dressing-gown. When the patient returns to he*r bed 
both the dressing-gown and the long night-gown should 
be removed. It is hardly proper for the patient to be 
around the room in the gown which she wears to bed. 
She contaminates her gown and then her bed. Unless 
her dressing-gown is freshly washed it is hardly proper 
for her to wear it over the dress she wears in bed. A very 
good plan is for a woman to have a perfectly clean bath 
robe to wear during labor when she gets out of bed. Before 
she steps on the floor the nurse should put on her stock- 
ings, which are to be removed when she returns to her 
bed. By this way the contamination of the bed by the 
dress which so often occurs will not happen. 

Bed. — The bed itself next requires the nurse's attention. 
A single or three-quarter bed is more convenient than a 
wide double bed. If possible it should always stand 
so that it may be approached from both sides. If the 



LABOR-BED 



137 



mattress of the bed is lower than the side pieces, which 
happens especially in folding beds, it must be raised 
to the level of or above the sides by putting under it 
blankets or boards. Feather beds, which are once in a 
while found, must be removed. The mattress should be 
covered with a rubber sheet. In the outfit already given 
you will notice that a rubber sheet three yards by one and 
one-half yards is provided. This is cut in two so as to 
make two pieces, one a yard and three-quarters by one 

Fig. 59 



Labor-bed, with first rubber sheet and draw-sheet. After labor this 
becomes the puerperal bed. 



and one-half and the other one and one-quarter by one 
and one-half yards. The larger sheet is placed over the 
mattress on the side on which we expect to work, generally 
the right side of the bed. It will cover the mattress 
except about one foot at the upper and one foot at the 
lower end, and is drawn over so as to cover the edge. 
Over this protecting rubber cloth is a draw sheet folded 
so as to be about four feet wide and then another sheet 
covering the bed. Over this is laid the smaller rubber sheet, 



138 



LABOR 



which becomes the rubber draw sheet. This sheet extends 
eight or ten inches over the edge of the bed. Over this 
rubber draw sheet is placed another sheet folded so as 
to be about three and one-half feet wide. On this last 
sheet the patient lies, unless pads have been especially 
prepared. The patient is covered with a clean sheet 
and with one or more clean blankets if necessary. The 
pillows are of course provided with clean pillow slips. 



Fig. 60 




Labor bed complete, with rubber and cotton draw-sheets. 



Rubber Draw Sheet. — The second rubber sheet, that is, 
the rubber draw sheet, enables us to protect the bed so 
that a change after labor is ordinarily unnecessary. By 
removing it with the pads and sheets over it a dry bed 
is left for the patient without further manipulation. 
The rubber draw sheet is also of great value if we have to 
give the patient a douche. To give a douche, for example 
in a case of postpartum hemorrhage, the patient is pulled 
to the very edge of the bed (Fig 74), so far that the outer 
hip is partly over the edge, the pads and draw sheets 
covering the rubber draw sheet are removed, the rubber 



LABOR-BED 



139 



draw sheet is pulled over far enough so that its lower 
end leads into a pail or slop jar placed at the edge of the 
bed, and its edges are turned in so as to form a trough 
which will conduct the water into the pail. In this way a 
large douche of gallons if necessary may be used without 
wearying or even disturbing the patient. In case of any 
operation where it is necessary to turn the patient across 
the bed the draw sheet is arranged in the same way. This 
use of the draw sheet for the giving of douches is preferable 
to the use of a drainage pad like the Kelly pad. The 
latter cannot be cleaned easily and it is certainly risky to 
carry it from one patient to another. The rubber sheet is 
so cheap that a patient always has a new one for use in 
each case. If a patient is too poor to get a rubber sheet, 
a piece of while oil-cloth as recommended in the cheap 
outfit will answer very well the same purpose. 

Bedsheets. — Ordinarily clean sheets for the bed and 
for pads answer all requirements. Old cotton sheets 
will do quite as well as expensive linen sheets. They 
should be carefully washed in clean water, dried, 
ironed, and put away together not to be disturbed until 
they are used. While such sheets are not absolutely 
sterile they are perfectly safe. Even if sterile sheets arc 
used they will remain sterile on the bed but a moment. 
The important thing is that the sheets shall be well 
washed and boiled in clean water, ironed by one who 
has clean hands, and then put away where they will not 
be handled by anyone who has dirty hands. There is no 
objection to sterilizing the sheets if the patient or nurse 
have access to a sterilizer. 

Pads. — If obstetrical pads are desired they should be 
made of sterilized cotton and sterilized or antiseptic 
gauze. The cotton is enclosed between a double layer 
of gauze and quilted so as to hold it in position, using 
clean or sterilized thread for this purpose. They should be 
about a yard square and may be sterilized after they are 
made. Pads made of common cotton and cloth are not as 
good or as safe as plain sheets unless thoroughly sterilized. 



140 



LABOR 



Disinfection of the Genitalia. — After the nurse has given 
her patient an enema and bath and prepared the obstet- 
rical bed she proceeds to disinfect the genital region. The 
difficulties in the way of a thorough disinfection of the 
skin which have been described in speaking of the dis- 
infection of the hands are considerably greater here. 
The creases and folds in the skin about the vaginal and 
anal openings and in the thigh and groin flexures together 
with the growth of hair makes the region very hard to 
clean. At the same time it is badly contaminated because 
of the glandular and vaginal secretions and the fecal con- 
taminations. The sensitiveness of the skin and vulvar 
structures prevents the thorough mechanical cleaning 
that is possible with the hands. On account of these 
difficulties it is impossible to completely disinfect or 
sterilize the genital region at one attempt. Repeated 
efforts during the course of the labor will perhaps succeed. 
The best that the nurse can hope to do at first is to remove 
the greater number of the contaminating germs and 
render the remainder innoccuous by the use of disinfectants. 
In this way the patient may be prepared so that it will 
be possible for an internal or a vaginal examination to 
be made without serious risk of carrying infectious mat- 
ter into the interior of the obstetric canal. 

Shaving. — Considerable of the difficulty in the dis- 
infection will be avoided if the patient be shaved. In 
the preparation for a gynecological operation this is always 
done. Many patients, however, object to the shaving, and 
as some physicians consider it not absolutely necessary 
they omit it in simple cases. Whenever any kind of an 
obstetrical operation has to be performed, or when the 
labor is unusually prolonged and the chances for infec- 
tion thereby increased, the hair should always be 
removed. 

To clean the genital region a large amount of soap 
and water, as well as a disinfecting solution, must be used. 
To do this without soiling the bed, the patient must lie 
upon her back, having under her a suitable receptacle for 



CLEANING THE GENITALS 



141 



receiving the water. The proper way to proceed will now 
be described. 

Method of Cleaning the External Genitals — Gather up a 
sheet in the middle so that it makes a V; with this cover 
the patient's legs and thighs with the middle of the sheet 
over the lower abdomen, leaving the genitals exposed. 
If more convenient two sheets may be used, one for each 
limb, or the sheet which covers the patient may be left 
over the left limb and a large towel may be used to cover 
the right. Slip under the patient, lying on her back, the 
thighs flexed, a douche or a bed pan. Take a basin of 
warm water with a few pieces of absorbent cotton or 
sterilized gauze for sponges and a cake or tube of soap. 
Wash the perineal region thoroughly with soap and water, 
including the inside of the thighs. Wash separately the 
anal region, being careful not to rub from the anus toward 
the vulva. Use plenty of water and do not separate the 
labia majora to wash their inner surfaces and the outlet 
of the vagina until after the outer region has been 
thoroughly cleaned. Always get a fresh basin of water 
before washing inside. It is best to use plenty of sponges 
and not dip the sponge that has been used in rubbing the 
skin into the basin. When the patient is not shaved the 
hair, particularly if long and thick, should be cut with 
the scissors. A satisfactory washing of the vulva with 
soap and water will take at least ten minutes. Then a 
basin of disinfecting solution containing sponges is sub- 
stituted for the basin of soap and water. A strong sub- 
limate solution of 1 to 500 to 1 to 1000 is perhaps the most 
efficient and best to use. A 2 per cent, solution of car- 
bolic acid or a 1 per cent, lysol solution may also be used. 
With this solution the cleaning is done in the same order 
as before, that is, the anal region, the inner surface of 
the thighs, the outer surface of the labia majora are first 
washed, then the large lips are separated and their inner 
surfaces with the opening of the vagina are thoroughly 
covered with the disinfecting fluid. The inner structures 
are not rubbed so much as the outer but plenty of the 



142 



LABOR 



solution is allowed to flow over them, being squeezed 
out of the saturated sponges. 

The irrigator or douche may be employed in the wash- 
ing. The water from the tube is allowed to flow over the 
genital region, which is in the meantime scrubbed with 
the cotton sponges. 

Vaginal Douches. — The vaginal douche should not be 
given unless it is specially ordered by the physician. 
While some obstetricians use the preparatory douche in 
all cases of labor, its use is generally confined to those 
cases where there is some vaginal infection. If the douche 
is given it follows a thorough disinfection of the external 
genitals just described. The physician will direct what 
solution is to be used. 

Vaginal Pad. — After the disinfection of the genitals an 
antiseptic pad is sometimes placed against the vulva, 
especially after the rupture of the membranes, to absorb 
the escaping liquor amnii. If such a napkin is used it 
should be changed frequently. Under no circumstances 
should a napkin be allowed to remain too long, for it is 
likely to become saturated and dam back into the vagina 
the discharge, producing a condition that is favorable 
for its contamination. 

Douche-pan. — The douche-pan and bed-pan should be 
handled with some care. A nurse who had prepared a 
bed with sterile sheets has been known to take a douche- 
pan from the floor under the bed and put it on the 
sterilized bed under the patient. A floor, especially a 
carpeted floor, is, of course, thoroughly contaminated, and 
a douche-pan thus used will contaminate the bed. Before 
it is used it should be thoroughly cleaned either by boiling 
it or washing it well with soap and water or some disin- 
fecting solution. After use it should be emptied and then 
placed on a table or stand that is covered with a clean 
sheet or towel. 

Solutions. — The nurse may now prepare the solutions 
and sponges that will be needed in the further conduct 
of the labor. A stand large enough to hold two or three 



LABOR-ROOM 



143 



bowls and pitchers should be placed near the foot of the 
bed, covered with a clean sheet. On this stand or table 
is placed a basin with a disinfecting solution, sublimate 
1 to 1000 or lysol 2 per cent, for washing the hands and 
another bowl for the solution with the sponges. If there 
is not a stationary washstand convenient another bowl 



Fig. 61 




dropjoer-* 
eye jo/uft, 



m edec>nes\ • , 
hypo Syrtr. 



., ■Sferel/ier 
' ~with instruments 

T . Stere/tzer Cover 
r /v/'M Jc/ssors, Tape *- 
J aspiraring cetheTer 
<STeriJe basin 
for placenta 



basket 



Window Window 

Arrangement of bed, tables, etc., for a labor-room in a private house. 



with hot water and brush and soap for the preliminary 
washing of the hands is necessary. The sponges consist of 
pieces of absorbent cotton the size of the hand or similar 
pieces of sterile gauze. A small bowl like a finger bowl 
or eating bowl for alcohol is also needed. A pitcher for 
hot water and one for cold water is provided Unless 
the hydrant water is known to be bad it will answer very 



\ 



144 



LABOR 



well for washing the hands and external genitals. The 
nurse should have provided, however, a gallon or two of 
cold, boiled water for eventual use in the giving of salt 
solution injections under the skin or in giving of douches. 
The nurse must always see that there is an unlimited 
amount of water at hand. It may happen that after 
labor a severe hemorrhage occurs. To control this a 
continual douche of hot water may be required for half 
an hour. Any delay in securing this douche may be fatal; 
hence provision must be made for a continual supply. 




Protection of the Floor.— The nurse should next take a 
large piece of oil-cloth, two to three yards square, that 
has been provided for the floor, and place it under and at 
the side of the bed. This is especially necessary if there 
is a carpet'on the floor. A slop jar or pail for the soiled 
sponges, etc., should not be forgotten. 



EXAMINATION OF PATIENT 



145 



Douche Bag. — The nurse may next prepare the douche 
bag. If a new bag has been provided it will only be 
necessary to boil it for two or three minutes. If we have 
to use an old bag that has perhaps become black by use 
and age it must be first thoroughly scrubbed in soap and 
water. The tube in particular must be thoroughly 
washed. Then the bag is placed in a kettle to boil for 
ten minutes. A cord or hook is also provided so that the 
bag can be fastened either on the head of the bed or in 
some convenient place. It is then wrapped in a clean 
towel and laid away until needed. 

The douche tube, scissors, the tape, or other ligature for 
the infant's navel are next boiled and laid away in sterile 
gauze or towel. In the outfit previously recommended 
(page 130) sterile ligature is provided. The catheter that 
may be needed for drawing mucus from the baby's 
mouth is also cleaned and laid at hand. 

The nurse may next utilize the time that she does not 
need to devote to the patient in preparing napkins for 
future use. They are made in the following way: Apiece 
of gauze about thirty inches long is cut off from the roll 
and spread out on a clean towel. On this is placed a strip 
of cotton about fifteen inches long and five inches wide 
and of the thickness of a cotton layer. This is enclosed 
in the gauze and is ready for use. Eight or ten of these 
napkins may be made and folded up in a sterile towel 
ready for use. 

After the nurse has prepared the blankets and the bed 
for the reception of the baby she is now able to give her 
entire attention to the patient. 

Examination of Patient. — In the absence of the physi- 
cian, when the nurse is alone with her patient, she must 
keep track of the condition of the patient and the fetus 
and the progress of labor. The general rules for examin- 
ing a patient that apply in all other cases hold here. 
The rate and character of the pulse should be taken fre- 
quently and recorded. The temperature also is important. 
The amount of food and drink taken should be noted. 
10 



146 



LABOR 



If the patient vomits, which is not infrequently the case, 
this fact should also be recorded, as well as the action 
of the bowels and the bladder. Any headache or dizzi- 
ness should be inquired into. The frequency and duration 
of the pains should be accurately studied and reported. 

The position and presentation of the child and its 
location or, in other words, the progress of labor are 
determined by both external and internal examinations. 
Internal or vaginal examinations are rarely necessary 
and should never be made unless ordered by the attending 
physician. The external examination comprises both the 
abdominal examination and the external examination of 
the genital region. 

Abdominal Examination. — Inspection. — The abdominal 
examination is made by inspection or sight, by palpation 
or touch, and by auscultation or hearing. On uncovering 
the skin we see the general size and shape of the abdomen 
as well as the movements due to the child. The uterine 
tumor fills a considerable part of the abdominal cavity 
extending from the pelvis to the chest. When the child 
lies in the normal position and posture the long axis of 
the tumor is lengthwise with the body. As a rule the 
uterus does not lie directly upon the spinal column but 
is more to one side. In the majority of cases it lies more 
to the right side. In a cross presentation the shape of the 
uterine tumor is different. It is broader and not so long; 
hence a cross presentation can be determined generally 
by inspection. When looking at the uterus we frequently 
see the movements caused by the motions of the fetus. 
These, of course, show that the fetus is alive. 

Palpation. — By palpation we determine the presenta- 
tion and location of the child as well as the question of 
the fulness of the bladder and the condition of the uterus. 
All these questions can be determined much better by the 
external examination than by the vaginal examination. 
It is rarely absolutely necessary that an internal examina- 
tion be made in labor especially if the attendant can 
remain with the patient. 



PALPATION OF ABDOMEN 



147 



In making the abdominal palpation a routine should 
be followed so that the fewest possible manipulations 
need be made. With a little practice a nurse may deter- 
mine with two or three manipulations within half a minute 
and with almost absolute certainty how and where the 
baby lies. 

First Manipulation. — In the first manipulation the 
nurse, standing on the right side of the patient and facing 
her head, places the hands, one on each side of the upper 
part of the abdomen so as to grasp the fundus of the uterus 
through the abdominal walls. The fingers are extended 
and the whole hand lies firmly but lightly on the body. 
Now by moving the hands back and forth, changing their 
position but little on the skin, the part of the fetus that 
lies in the fundus will be moved from side to side and be 
thus felt. We have to determine whether this part be the 
head or the breech. It is generally possible to distinguish 
the head by its size, hardness, and shape. If the uterus 
contracts during this manipulation the findings are 
indefinite and we must wait, keeping the hands on the 
abdomen, until the contraction passes away. Sometimes, 
however, even when the uterus is relaxed, the breech of 
the child feels so large and hard that we are in doubt 
and must wait for the second manipulation to clear up the 
question. 

While making the examination of the fundus we often 
feel the small parts of the child. A foot, or leg, or knee, 
or sometimes a hand, is often violently forced against 
the abdominal wall and the examining hand. Sometimes 
we may grasp this small part of the child and make out 
quite clearly what it is. 

Second Manipulation. — In making the second manipula- 
tion the nurse turns around, facing the patient's feet and 
grasps the lower segment of the uterus through the fundus. 
The hands are kept well to the sides of the lower abdomen, 
the little finger and ring finger being pressed well down 
into the groin. Firm pressure must be made, but very 
gently, so that the patient does not feel pain and resist. 



148 



LABOR 



The chief work is done with the outer border of the hand 
and the ring and middle finger. The head, if presenting, 
is felt as a hard mass, which by patience can be outlined, 
and if it be not engaged in the pelvis can be moved from 
side to side. If the examination causes any contraction 
of the uterus we must again wait until the contraction 
passes away. 

Fig. 63 




Palpation of the abdomen to locate the presenting part. Second 
manipulation. 



By this manipulation we determine not only the location 
of the head in the lower segment of the uterus but also 
the position of the head. In the normal flexed posture 
of the child the line of the back is almost continuous 
with the back of the head, while the forehead forms a 
prominence or projection. In other words, the forehead 
projects a great deal more than the back of the head. 
Remembering this fact we have a means of determining 
the position of the child. While making the second ma- 
nipulation we feel a much greater prominence with one 
hand than the other. This prominence denotes the child's 
forehead, consequently the back of the head lies to the 
other side. By this second manipulation we also locate 
the head or determine the extent of its progress through 



PALPATION OF ABDOMEN 



149 



the obstetrical canal. If we feel the entire head movable 
above the pelvis it of course has not begun to enter the 
pelvis. When the head has nearly engaged in the pelvis 
we feel the back of the head not at all or with some diffi- 
culty, while the forehead is still easily made out. When 
the head has entirely entered the pelvis and we cannot 
reach it by the external manipulation, the hands then 
feel only the shoulders and the trunk. 



Fig. 64 




Palpation of the abdomen to locate the back. Third manipulation. 



Third Manipulation. — By the third manipulation we 
complete our examination of the position of the child by 
determining the position of the back. Turning so as to 
face the patient the nurse places one hand on the fundus 
over the breech of the child and presses down somewhat 
firmly in the direction of the axis of the uterus. In this 
way by pressing the breech toward the head she increases 
the curve or convexity of the back and makes it more 
prominent. Then she places the right hand first on one side 
of the abdomen and then on the other and outlines with 
it the position of the back. Often she can feel quite dis- 
tinctly the curve of the back against the abdominal wall. 
When this is not possible, she at least experiences greater 



150 



LABOR 



resistance on one side than on the other. This greater 
resistance denotes the back. 

It is evident that the child may lie exactly on its side, 
when the back will be directly to the side of the mother, 
or its back may be directed more toward the abdominal 
wall or toward the back of the mother. When the back 
of the child lies against the abdominal wall it is more 
easily made out by this third manipulation than when it 
is turned toward the back of the mother. In the latter 
case the small parts of the child, that is, the hands, elbows, 
arms, and lower extremities, are more easily felt. 

Importance of Determining Fetal Heart Tones. — The 
fetal heart sounds are generally best transmitted through 
the back of the child _and the corresponding portion 
of the uterine and abdominal walls. Consequently when 
the back of the fetus is turned toward the front of the 
mother's abdomen the heart tones are heard at their best. 
Their distinctness also depends upon the amount of 
liquor amnii and the amount of fat in the abdominal 
wall. In a head presentation they are generally heard 
best below the level of the umbilicus, while in a breech 
presentation they are best heard above this level. When 
the back of the child is turned to the left side they are 
heard to the left of the middle line, and when the back 
is to the right they are heard on the right side. Conse- 
quently the location of the area of the fetal heart tones 
helps us in determining the position of the fetus. In 
rare cases when we are unable to feel the back with cer- 
tainty the finding of the heart tones on one side or the 
other will help us to a decision. 

The counting and the observation of the fetal heart 
tones is the duty of the nurse. Almost our only way to 
study the condition of the child is through the study of 
the rapidity and character of the fetal heart beats; hence 
it is necessary for a nurse who is often responsible for a 
patient for hours at a time in the absence of the physician 
to be perfectly able to examine the fetal heart. She has 
two patients under her care and she is just as responsible 



AUSCULTATION 



151 



for the unborn child as for the mother. If during the 
absence of the physician the mother should die and upon 
the physician's return the nurse should be ignorant of the 
fact, she could hardly excuse herself to the physician 
or to the family. She should keep just as close watch 
upon the unborn child as upon the mother. Frequent 
examinations of the fetal heart, especially in a long and 
severe labor, must be made, and if she finds any change 
she must report this to the physician just as she would 
any unfavorable change in her other patient, the mother. 



Fig. 65 




Auscultation. Counting fetal heart tones with phonendoscope. 



Auscultation. — The fetal heart tones may be heard by 
listening with a stethoscope or phonendoscope or by 
applying the ear directly to the skin. The best way is 
with the phonendoscope. This instrument should be a 
part of the nurse's outfit and she should thoroughly 
understand its use. It should lie securely on the abdomen 
by its own weight and not be held or pressed against the 
skin. The way of finding the exact location of the heart 
tones is the same as in direct auscultation which, as it 



152 



LABOR 



involves a more difficult technique, will be described in 
some detail. 

After palpation, as described above, the nurse covers 
the patient with a sheet and kneeling by the side of the bed, 
corresponding to the supposed location of the back of the 
child, she applies her ear to the skin protected by the 
sheet. She should first listen at a point half-way between 
the navel and the symphysis pubis. Then if the heart 
tones are not distinctly heard at this point she should 



Fig. 66 




Auscultation. Counting fetal heart tones with ear applied to abdomen. 

carry the listening ear gradually to the side and then up 
and down until the whole lower quarter of the abdomen 
has been examined. In case she does not hear the heart 
at all she should then pass to the other side of the patient 
and examine the other section of the' lower quarter the 
same way, suspecting she has made a mistake in the ex- 
amination with her hands. If she still fails to find the heart 
tones she may examine the upper half of the abdomen in 
the same way. Still failing, she may apply her ear directly 



COUNTING FETAL HEART TONES 



153 



to the skin, for the sheet sometimes disturbs the hearing. 
If she is still unsuccessful she should place her hand over 
the fundus of the uterus as in the third manipulation in 
palpation and press upon the breech of the child so as 
to increase the curve of its back and bring it nearer the 
abdominal wall. Then she may be able to hear the sounds 
which were before obscured by the fruit water that 
separated the child from the wall of the uterus. Sometimes 
the sounds are brought out more prominently by having 
the mother turn on one side or another, generally turning 
so that the back of the child is uppermost. These exami- 
nations during labor should be made in the intervals 
between the pains, for the contractions of the uterus very 
frequently obscure the fetal heart tones so that they 
cannot be heard. Examining this way a nurse who is 
accustomed to listening to the fetal heart will almost 
always find it if the child be living. Its absence, therefore, 
together with all absence of fetal motion as felt by the 
nurse or mother, would create a strong suspicion that the 
child was dead. 

Counting Fetal Heart Tones. — In counting the fetal 
heart beats it is well for the nurse to count for fifteen 
seconds, then begin again and count for fifteen seconds 
more, repeating the counting this way for the minute and 
make a record of her findings by quarter minutes instead 
of by minutes. For example, she counts for the first 
quarter thirty-three, for the second thirty-five, for the 
third thirty-four, and for the fourth thirty-seven; this 
would be recorded, thirty-three, thirty-five, thirty-four, 
and thirty-seven. From this record one not only sees 
the total for one minute one hundred and thirty-nine, but 
also the irregularity in the fetal heart. 

At the beginning of labor the nurse will be informed 
by the physician where the fetal heart may be found or 
she will discover this for herself. Then she should count 
the sounds several times at intervals of about every half- 
hour in order to discover what is the normal heart beat 
of this child. Then she is in possession of the facts that 



154 



LABOR 



enable her to judge of the irregularity and changes in 
rate at a later stage of a severe labor. 

Rapid and Slow Fetal Heart Beats. — Very rapid and 
very slow heart beats show that the child is in danger. 
If the normal heart beat of the fetus is one hundred and 
thirty, a rate of one hundred and eighty shows considerable 
disturbance in the child's circulation. For a child whose 
normal rate was one hundred and fifty-five or one hun- 
dred and sixty a rate of one hundred and eighty would 
not be so important. A rate of one hundred or less is also 
generally a sign of danger. 

Irregularity in the Fetal Heart Beats. — A great varia- 
tion in the heart beat is also to be observed with care. 
If the count should be thirty-three, thirty-six, forty, or 
thirty, thirty-five, twenty-five, twenty-two we would feel 
some anxiety for the child and realize that it must be 
watched with great care. Uterine contractions frequently 
cause some irregularity in the fetal heart even in the 
early stages of labor. At a later stage these irregularities 
are more pronounced and if not too great may not be of so 
much importance. Irregularities that are noticed in the 
interval between the pains are probably of greater moment. 
Under any circumstances they call for unusually careful 
observation and, of course, record. 

Much less importance is to be attributed to the clear- 
ness with which the fetal sounds are heard. As has been 
stated this depends very much upon the position of the 
child. Since the position may change during the labor 
the sounds will vary in distinctness. After the mem- 
branes break and the fruit water escapes the sounds are 
generally heard more distinctly. If, however, the nurse 
has kept a careful watch of the sounds in the latter part 
of labor after the waters have escaped, and has a good 
basis for judgment as to the clearness of the sounds, then 
a marked change in their character, consisting of great 
diminution in clearness and distinctness, will be a good 
reason for thinking the child is in danger. 



INSPECTION OF GENITAL REGION 



155 



Inspection of the Genital Region. — The external examina- 
tion of the genital region consists of inspection and palpa- 
tion. By inspection we recognize the distention or pro- 
trusion of the perineum during a pain which indicates 
that the head begins to escape from the bony pelvis and 
press upon the perineum. As the head advances farther 
the vulvar lips begin to separate. Shortly after this the 
advancing part of the head is seen. All of these stages 
can be observed by the nurse and of course necessitate 
the more or less urgent call for the physician if he be 
absent. 

By inspection one also notices the character of the 
discharge from the vagina. When the membranes rup- 
ture the liquor amnii begins to escape and it continues to 
flow, as a rule, during the rest of the labor. It occasionally 
happens in a protracted labor that the fruit water becomes 
discolored. It has a dirty blackish color. This is due to 
the presence of the meconium which has been squeezed out 
of the fetus. The presence of the meconium in the liquor 
amnii in a head presentation indicates that the child has 
been subjected to dangerous pressure. It is therefore an 
important symptom, and should be noted and reported 
to the physician at once. 

Blood may be found in the vaginal discharge at almost 
any time during the course of labor. In the first stage of 
labor it generally denotes a spontaneous tear in the cervix. 
It is not very free in amount, and is of no special impor- 
tance. In rare instances it is due to an abnormal location 
of the placenta or to other serious complications which 
have already been discussed (see pages 90 and 95). In 
the second stage of labor the blood may come from a tear 
in the vagina. Rarely a severe hemorrhage occurs from 
rupture of varicose veins in the vagina. The hemorrhage 
should always be noted by the nurse when she is in 
charge of a case. 

Palpation of the Perineum. — Besides inspection, however, 
the nurse has another means of determining the progress 
of labor and one that may be employed before the 



156 



LABOR 



bulging of the perineum begins. This is palpation of the 
advancing part of the head through the skin just below 
the anus. It is most conveniently practised with the 
patient on her side. Standing behind her with the tips 
of the fingers resting on the skin below the sacrum the 
nurse presses inward during a pain and thus can easily 
determine if the head be approaching the outlet of the 
bony pelvis. This manipulation is quite valuable, for 
it enables one to judge concerning the progress of labor 
after the head has completely disappeared from the 
abdomen and can no longer be felt from above. During 
this stage of labor the nurse, who is forbidden to make 
an internal examination, is often uneasy in regard to the 
advance of the head. 



Fig. 67 




Palpation through the perineum. 



Internal or Vaginal Examination. — The value of internal 
or vaginal examinations in labor has been much over- 
rated both by physicians and midwives. Fortunately 



INTERNAL EXAMINATION 



157 



trained nurses generally have been taught that the making 
of internal examinations is not one of their duties. As has 
been stated, such examinations may be dangerous by 
carrying infecting germs into the obstetric canal. During 
an examination the membranes might be ruptured pre- 
maturely, causing, perhaps, a serious disturbance to the 

Fig. 68 




Method of making an internal examination. The nurse separates the 
labia and is about to introduce the examining ringers. 

progress of labor. They are, moreover, as a rule, quite 
unnecessary. A nurse in general practice might never be 
called upon during her whole life to make an examina- 
tion. Occasionally, however, a physician expects this of 
a nurse, and it is for this reason, at least, that she should 
know the proper mode of proceeding and have in mind 
what she should find. The examining hand should be 



158 



LABOR 



protected with a rubber glove. Although the glove inter- 
feres somewhat with the touch sense its use is quite satis- 
factory. A thorough disinfection of both hands should, 
nevertheless, be made. The front and middle finger of 
the right hand are generally employed. After the patient 
has been thoroughly washed and disinfected as well as 
possible, as has been previously described, the nurse, 
holding apart the labia so that the examining fingers 
may not come in contact with any outside contamina- 
tion introduces the fingers into the vagina. If lysol 
is used as a disinfectant there is no need of a lubricant. 
If the vagina seems somewhat dry or the vaginal outlet 
is rather small a lubricant may be desired. Great 
care must be used in selecting something which is not 
in itself contaminating. Ordinary vaseline, for example, 
in a half-filled box, which perhaps has been lying around 
the house for some time and into which many dirty 
fingers have been dipped, will doubtless be a source of 
danger. A boiled oil would answer the purpose. The 
tube of antiseptic soap or liquid soap which is recom- 
mended in the outfit is very well adapted for this purpose. 
It is not only clean and convenient to use, but it also 
leaves the fingers in good condition, as it can easily be 
washed off from the hands. 

The object of the internal examination is to determine 
the condition of the vagina, the possible presence of any 
growths in or deformities of the pelvis, the condition of 
the cervix, including its thickness and the amount of its 
dilatation, the location, position, and condition of the 
presenting part of the fetus. These objects should be 
kept in mind and the examination conducted with a 
certain routine so that as much as possible may be learned 
in as short a time as possible. The element of time is of 
great importance in making an internal examination. 
When the hands are not absolutely sterile an examination 
of half a minute may do no harm, because very few or 
no germs will dislodge to cause trouble and because there 
will be little danger of harmful abrasions, while an exami- 



INTERNAL EXAMINATION 



159 



nation of five or ten minutes will be much more likely to 
cause an infection. 

The nurse will, therefore, proceed with her examination, 
sweeping the fingers around the vagina and noting its 
smoothness or roughness, the amount of secretion, and 
the presence of any abnormality. During this process 
she will also notice the presence of any growths obstructing 
the pelvis as well as the shape of its walls. In particular 
she should notice the shape of the sacrum, whether it 
has the proper curve or not and the forward projecting 
coccyx. She should next feel for the cervix. You will 
remember that the uterine contractions first cause the 
obliteration of the vaginal portion of the cervix and then 
gradually open the cervix until the uterus and the vagina 
form a continuous canal. Sometimes the obliteration 
of the cervix has taken place before the real labor begins, 
having been produced by the preparatory pains. By the 
examining fingers we first find whether this vaginal portion 
still exists or not. If it is obliterated we next determine 
whether the cervix is open, and if so how much. The 
degree of opening of the cervix is expressed by estimating 
how many fingers it will admit, or after it is half dilated 
by indicating the width of the rim that remains. We say, 
for example, that the cervix will admit one finger or two 
fingers, or that a rim of one or two fingers' breadth still 
remains. Sometimes the cervix is thin, its border feeling 
not much thicker than a sheet of paper; at other times it 
is thick and feels, perhaps, somewhat like a swollen, lip. 

In making the examination of the cervix, we also 
determine whether the membranes are ruptured or not. 
If they are intact and the cervix is open one will feel the 
bag projecting into the cervix more or less, especially 
during a pain. If it has been ruptured, the finger will 
come into contact with the head or presenting part with- 
out any intervening membrane or tissue. If the mem- 
branes are intact the examination must be made very 
carefully so as not to rupture them. About all the nurse 
will be expected to do will be to recognize the presenting 



160 



LABOR 



part, whether it be a head or face, the breech, the hand or 
foot, and determine whether it is in the inlet, excavation, 
or the outlet. If the cord be prolapsed the condition 
should be recognized, for it is a very important one and 
calls for immediate treatment. 

Care of the Bladder during Labor. — It occasionally 
happens that a patient cannot urinate voluntarily during 
labor. This ischuria may be due to the pressure of the 
child against the urethra. The bladder may be injured 
by distention. Moreover, such distentions often interfere 
with the abdominal contractions, which are important 
elements in the second stage of labor. It may, therefore, 
become necessary to draw urine from the bladder. The 
presence of any considerable amount of urine will be 
recognized at once by the nurse when she makes the 
abdominal examination. A distended bladder will easily 
be felt above the pubis, perhaps reaching half-way up 
to the navel. If the head is in the pelvis and the bladder 
entirely displaced into the abdomen it will be very easy 
for the nurse to exaggerate the amount of fluid it con- 
tains, as the bladder will form such a mass in the lower 
abdomen. When the head is in the pelvis six ounces 
of urine in the bladder will cause a considerable tumor. 

Catheterization.— Under these circumstances drawing the 
urine with the glass catheter that is used in the puerpe- 
rium and in other conditions is not desirable and often 
not possible. The catheter might not reach the urine, 
and there would be some danger of its breaking by the 
pressure of the child's head during the pain. For this 
purpose a fairly large soft rubber catheter is recommended. 
It should be used after a thorough washing of the patient 
as before described, and with the same precautions that 
are used in other cases and which will be more particularly 
considered when we come to speak of catheterizing in the 
puerperium. 

Shall the Patient Remain in Bed? — In considering 
further the conditions of labor we must allude to the 
question that is frequently asked the nurse as to whether 



MANAGEMENT OF LABOR 



161 



the patient can sit up or walk about or whether she would 
better remain in bed. Also, if in bed, in what position 
should she lie? After the membranes break the patient 
should remain in bed. By so doing she will lose less of 
the fruit water. Its retention, as much as possible, is of 
advantage both to her and to the baby; consequently 
in an early or premature rupture of the membranes the 
patient must remain in bed during the whole labor. 
Even when the rupture occurs two or three days before 
labor begins the same rule applies. 

If the patient is weak she would better remain in bed. 
There is no particular advantage in having her sitting 
or walking about the room. The labor may progress a 
little faster, perhaps, but, on the other hand, she is apt 
to lose some rest that she might obtain in bed. How- 
ever, if she feels better up, if there is no contra-indication, 
she may be allowed to do as she pleases. 

In bed a patient generally wishes to change her position 
occasionally. As a rule the pains are apt to be more 
vigorous when she lies on her back. If she wishes to 
lie on her side she is generally directed to lie on the side 
corresponding to the back of the child. This position 
favors the normal mechanism of labor. 

Nourishment. — In a long labor lasting a day or more 
the question of nourishment becomes important. In 
a short labor it is often impossible for the patient to eat 
much because of the disturbance of the stomach. Severe 
pains may act in one way or another to cause an evacua- 
tion of the stomach contents. In a long labor there are apt 
to be intervals where the pains are not so severe. These 
must be utilized to give the patient nourishment and 
stimulants. Sometimes milk with lime water and brandy 
is best borne. These cases, however, always permit of 
the presence of the physician, who will, of course, assume 
the responsibility. 

Moral Support. — An extremely important part of the 
nurse's duty is to furnish moral support to her patient, 
who suffers from both pain and fear. While the pain 
11 



1(32 



LABOR 



varies greatly in intensity and is no doubt often very 
acute and quite exceeds any other kind of pain to which 
people are ordinarily subjected, yet it is made much 
worse to bear by unnecessary fear. The patient fears 
that the pain will become greater and quite unbearable. 
She fears that she will become exhausted. She fears that 
all is not going well, that some operation will be necessary. 
Often she has vague and indefinite, but none the less 
real fears, that cannot be described. If these fears can 
be dispelled, if the patient could be made to believe that 
her pains will never be greater than she can bear, that 
she has nothing to fear, that she is only suffering as mil- 
lions of women have suffered in the past and as hundreds 
are suffering every hour she will be relieved of an impor- 
tant element of her distress. 

Analgesia and Anesthesia. — Many efforts have been 
made to discover a means by which pain may be done 
away with. Various drugs have been used as analgesics 
or pain annihilators. Morphin, chloral, and other drugs 
that have any effect interfere so much with the uterine 
contractions or they so endanger the fetus that they 
cannot be used to such an extent as to relieve all pain. 
"Twilight sleep," recently used in a few foreign clinics, 
is a stuporous condition secured by repeated injections 
of morphin and scopolamin. It requires much care 
and the constant watchfulness of the physician. It is 
not devoid of risk, and the responsibility for its manage- 
ment should not be imposed upon nor assumed by the 
nurse. The anesthetics chloroform and ether have been 
much used to alleviate suffering. The discoverer of 
the anesthetic properties of chloroform, the celebrated 
obstetrician Sir James Y. Simpson, hoped that he had 
found a means of rendering childbearing painless. Our 
experience shows us that while anesthetics are very 
valuable in certain stages of labor, and while they may 
be used in the last part of labor so as to control the most 
severe pain due to the expulsion of the child, they cannot 
with safety be used during the whole course of confinement. 



ANESTHETICS 



163 



Ether or Chloroform? — To the nurse is frequently en- 
trusted the duty of giving the anesthetic, and she should, 
therefore, take every opportunity to perfect herself in the 
technique of its administration. Both ether and chloro- 
form are employed. While in this country, in general 
surgery, ether is more used than chloroform, in obstetrics, 
chloroform has been used almost exclusively until the 
last five or six years. Recently a good many obstetricians 
have begun to use ether in labor more extensively, and 
believe that it has the advantage over chloroform, that it 
does not as much interfere with the uterine contractions, 
that when the contractions are stopped by the anesthetic 
they begin sooner upon its withdrawal, and that it is safer 
and more pleasant to use. Especially at night, when there 
is a gas or lamp flame in the room, chloroform is decom- 
posed and a very irritating gas is formed. Ether is inflam- 
mable if brought near the flame. If great care is used, 
however, in opening the can and keeping the ether some 
distance from the flame there need be no danger. 

Administration of Ether. — Ether is given generally 
with some kind of a cone or it may be given on a mask 
like chloroform. About a dram is sprinkled over the 
cloth in the cone at a time. In the beginning of the 
administration it should be held an inch or two from 
the face so that the patient will not be frightened. The 
ether is generally given only during the pain. In this way 
the pain is diminished, but consciousness is not entirely 
obliterated. Since the nurse will use the anesthetic 
only under the direction of the physician, she will, of 
course, be guided by him as to the amount employed 
and the degree of anesthesia produced. 

Administration of Chloroform. — The method of giving 
chloroform differs from that often employed with ether 
in the fact that the former must always be well diluted 
with air and that it is given in very much smaller amounts : 
a few drops only at a time sprinkled over a cloth held 
over the patient's nose and mouth. The well-known mask 
may be used or a thin cloth, like a handkerchief, may be 



164 



LABOR 



supported on the fingers. The back of the hand is laid 
over the face, the nose being between the middle and 
ring fingers and the handkerchief held by them from 
contact with the skin. In dropping chloroform from 
the bottle it is best to cut a groove in the cork through 
which the chloroform escapes in small drops. 

While the anesthetic may give much relief during the 
last part of the second stage of labor, it cannot, as a rule, 
be used to any great extent until the cervix is open, and 
the patient must, therefore, bear a good deal of pain. 



Fig. 69 




Support of the back during labor. 



Support of the Back. — Mention has been made of the 
value of massage as a preparatory treatment during 
pregnancy. It diminishes abnormal sensibility and thus 
proves a great aid during labor. One measure by which 
the pain may be at times somewhat lightened, very old but 
none the less important, may be added. This is the 
support of the back. During certain stages of labor, 
under certain conditions, pain in the back is intense. 



MANAGEMENT OF LABOR 



165 



Whether this pain be due to pressure on the large 
nerve trunks found in this region or to the stretching of 
the posterior joints or to some other causes, it is a fact 
that it may be relieved by firm pressure. This is best 
applied when the patient is on her back, by placing the 
hand under the sacrum with one finger just at the upper 
border of the hip bone and resting the arm on the bed as 
a support, raising up the back with the hand. 

Pulling. — When the patient comes to the second or 
expulsive stage of labor she has an inclination to support 
the body in such a way as to obtain the most power from 
the abdominal muscles. This leads her to brace her feet 
so as to fasten the lower part of the trunk and also to 
immobilize her chest so as to make the best possible use 
not only of the muscles of the abdominal wall but also 
the diaphragm. Pulling with the arms further than 
this is probably of little value, yet this action seems an 
unconscious accompaniment of the abdominal work. 
The patient may be encouraged to immobilize herself by 
taking hold of the rounds at the head of the bed if her 
bed be of such construction; otherwise she may grasp 
the hands of her nurse, or perhaps it is just as well 
to grasp her hands together. It is quite unnecessary for 
the patient to pull herself all over the bed in her frantic 
efforts. Not only is the cleanliness of the bed thus de- 
stroyed, but the attendant is very much handicapped in 
his efforts to manage the labor. 

Prevent Contamination of Genital Region. — As the head 
approaches the outlet its pressure behind forces out any 
contents of the rectum. These will, of course, contami- 
nate the bed and also probably the vulva and vagina. 
The nurse must at once collect upon the sponges that 
have been prepared for that purpose any particles that 
may be discharged from the anus. 

Supporting the Perineum.— As the head is expelled from 
the vulva it becomes the nurse's duty to prevent the tear- 
ing of this opening. Since the tear is generally through 
the perineum this manipulation is called protecting or 



16G 



LABOR 



supporting the perineum. A mistaken idea concerning 
this manipulation is quite common. Many think it 
consists of pressing back the perineum by holding the 
hand against it. The importance of the subject is great, 
for tears lead often to subsequent disturbances which 
seriously affect the health and comfort of the patient. 
To understand properly the method of preventing tears 
we must for a moment study the way in which tears are 
produced. 

Many tears are unavoidable. When the circumference 
of the child's head is greater than any opening that is 
permitted by the elasticity of the outlet a tear must 
result. Under the most favorable conditions, where labor 
is managed in the best possible manner, tears occur in 
about one-third of all primiparae. In these cases all the 
attendant can do is to prevent the extension of the tear 
as much as possible. 

Unnecessary tears are avoided by preventing a too 
hasty exit of the head, thus securing a gradual dilatation 
and by causing the head to make its exit in the most favor- 
able position so that it passes through the vulva in its 
smallest circumference. 

Prevent Rapid Expulsion. — When the uterine and abdomi- 
nal forces are very powerful the head may be forced 
along so fast that the outlet has not time to enlarge nor- 
mally and is torn. In such cases the head should be held 
back. In general the head should never be allowed to 
make its exit during a pain. With each pain the vulva is 
distended more and more until at the last, in the interval 
between the pains, the head is pressed out by the hand 
placed behind the anus, resting over the face against the 
perineum. 

Keep the Head Flexed. — The head is in the most favor- 
able position to pass through the vulva without lacerating 
it when it is flexed as much as possible. When in this 
position the largest circumference that passes through the 
vul va is the suboccipitofrontal. Unless the occiput is 
well through the vulva when the extension occurs a larger 



PREVENTING TEAR OF VAGINAL OUTLET 167 



Fig. 70 



'v. 




Head passing through vulva in the attitude of flexion. Compare 
the suboccipitofrontal diameter, which denotes the stretching of the 
vulva with the occipitofrontal diameter in Fig. 71. 

Fig. 71 




Head extended in exit. Note that the occipitofrontal diameter here 
denotes the distention of the vulva instead of the shorter suboccipito- 
frontal diameter in Fig. 70. 



168 



LABOR 



circumference, the occipitofrontal, will have to be accom- 
modated. From this it follows that the nurse should 
strive to keep the head well flexed and be sure that the 
occiput has passed out of the vulva and the nape of the 
neck appears before extension is allowed to occur. With 
these two principles clearly in mind she will be able, after 
she has had some experience, to secure the best results. 

Position of Patient during Delivery. — The patient may 
be delivered lying on the back or on the side. If she 
lie on the back the hips should be somewhat elevated by 
one or two extra pads. Under no circumstances should 
she be allowed to assume a posture where the hips are 
sunk into the bed. In such a position the attendant 
would have absolutely no control of the perineum. The 
best control at least with beginners is probably ob- 
tained with the patient lying upon the left side. With 
the patient in this position, her hips being flexed, the 
attendant gets behind her, the left arm between the thighs, 
the hand being in a position to control the movements of 
the head; with the right hand she is able to press against 
the forehead of the child, thus securing proper flexion 
and at the same time, with a sponge to protect possible 
contamination, through the anus. 

When the patient lies on her back the attendant sits 
at the side of the bed facing her and places the right 
hand, protected by a sponge, over the anus so as to keep 
the head flexed and prevent its too rapid expulsion. 
With the left hand the back of the head is pulled forward, 
if necessary, until the occiput is well through the vulva. 

Delivery of the Body. — As soon as the head is born 
the attendant examines to find if the cord be around the 
neck, removes it by pulling it over the head if that be the 
case, wipes the face of the child, supports the head with- 
out pulling on it (see Fig. 56), and waits for the expul- 
sion of the body. This follows, in some instances, almost 
immediately, and generally with the next pain, within 
two or three minutes after the birth of the head. Only 
rarely is any assistance required. W T hen the nurse believes 



LIGATION OF CORD 



169 



that the child is in danger on account of finding irregular 
heart tones, and there is several minutes' delay after the 
birth of the head, she may assist the delivery of the body 
by pressing on the uterus through the abdomen. During 
the birth of the shoulders and trunk there is renewed 
danger to the integrity of the vulvar outlet or perineum. 
Quite often a perineum that has remained intact during 
the careful passage of the head is torn because of a sudden 
exit of the shoulders. Sometimes also the elbow escapes 
shortly after the shoulder and makes a tear in the peri- 
neum. The circumference of the body and shoulders is 
almost always a little less than that of the head, and they 
should not produce a laceration. It is only necessary 
to observe the same rule that has been given for the 
delivery of the head. They must be brought through 
slowly, and if necessary in an interval between the pains. 
The same rule holds in the delivery of the elbow. 

After the body is born the child is covered with a warm 
blanket and allowed to lie between the thighs of the 
mother until the pulsation of the cord ceases, when the 
cord is tied and the child removed. The method of caring 
for the child and tying the cord will be described when 
we come to speak of the care of the infant. 

Ligation of the Cord. — The cord is tied in two places, 
about two and four inches from the child, and cut between 
the ligatures. The ligature next to the child must be 
tied tightly to prevent hemorrhage. The chief object 
of the ligature on the placental side is to prevent the 
soiling of the bed with the blood which fills the vessels 
of the cord and the placenta. In case of a twin pregnancy 
there may be a connection between the circulation of 
the children, when the second ligature would be necessary 
to prevent the second child from bleeding to death. 

It is convenient to place another ligature around the 
cord near the vulva and remove the outer piece of cord. 
Very slight traction is made in order to pull out any loops 
in the cord which may remain in the vagina. Then a tape 
is tied around the cord just at the vaginal outlet and the 



170 



LABOR 



outer portion cut off. The placental end will then retract 
within the vagina. The patient may now be cleaned and 
a vulvar dressing applied. When the placenta is expelled 
from the uterus and remains in the vagina the cord will 
be pushed out from the vulva and will thus indicate the 
location of the placenta. 

Management of the Third Stage. — Aiter the birth of the 
child begins the third stage of labor, the birth of the 
placenta, and to this we next give our undivided attention. 
The nurse, if she happen to be alone with her patient, 
should not leave her side. When the baby is separated 
it is quickly placed in its previously prepared bed and 
needs no further care. The mother should have constant 
attention on account of the possible danger of hemorrhage. 

As soon as the child's body is born the nurse should 
lay her hand upon the abdomen and watch the uterine 
contractions. As a rule it is not necessary for her to 
rub the abdomen or make any particular manipulations. 
The pressure of the hand will, perhaps, cause a slight 
stimulation to the uterus. The chief object, however, 
is careful observation. The uterus will be felt during 
a contraction as a hard body, almost like a stone, ex- 
tending perhaps two-thirds of the way to the navel. The 
hard contraction lasts perhaps a minute, when relaxa- 
tion begins; it then becomes larger and softer. It should 
be possible, however, always to outline it. The period 
of relaxation varies also in length. These alternating 
relaxations and contractions continue until the placenta 
is expelled. 

The placenta may be expelled by the first contraction 
after the expulsion of the child or it may not be expelled 
for several hours. If there is no urgency on account of 
hemorrhage or because of a serious condition of the 
patient the nurse need not be worried over the delay in the 
expulsion of the after-birth. She will quietly await the 
appearance of the physician, keeping, as said before, a 
close watch upon uterine contractions. 

When the placenta appears at the vulva the nurse must 



MANAGEMENT OF THIRD STAGE 



171 



endeavor to prevent the tearing of the membranes so 
that no part of them are retained in the uterus. For this 
reason she holds the placenta in the hand and gradually 
draws it away as the membranes peel off from the lower 
segment and pass through the cervix. Patience and avoid- 
ance of any unusual traction are all that are needed. 

After the placenta is born it should be placed in a 
basin or other receptacle and examined to determine 
whether it is intact or whether a part has been left in the 
uterus. First the uterine surface is observed and the 
absence of any lobes noted. Then the membranes are 
arranged as carefully as possible in their natural position. 
The location of the tear through which the child escaped 
is noted and the completeness of the membranes deter- 
mined. The placenta is then set to one side for the 
inspection of the physician. 

With the placenta comes, frequently, some clots of 
blood which have accumulated behind it and sometimes 
fresh blood. A contraction of the uterus which follows 
after the expulsion of the placenta should prevent hem- 
orrhage of any considerable duration. A hand placed over 
the abdomen now feels the uterus contracted as before, 
but it is soon in a state of almost continuous contraction. 
There are, at first, periods of relaxation, but these periods 
are shorter and less pronounced. In normal cases, such as 
are now being described, the continuous, firm contraction 
of the uterus at the end of fifteen or twenty minutes 
convinces the nurse that all danger of postpartum hemor- 
rhage is over. As a rule, however, she should not leave 
the patient in less than thirty minutes after the birth of 
the placenta, and then she should keep close watch of the 
uterine contractions for another half-hour. 

As soon as the child is born and wrapped in a warm 
blanket the wet pads under the mother are exchanged 
for dry ones, so that she may lie in comfort during the 
third stage of labor. After the birth of the placenta, as 
soon as it is evident that there is no serious hemorrhage 
to combat the soiled pads and draw sheets are removed, 



172 



LABOR 



the patient is cleaned thoroughly and the napkin and 
bandage are applied, as will be directed in the next 
chapter. The washing of the patient and changing her 
from the childbed to the lying-in bed is accomplished 
without distracting our attention from the condition of 
the uterus. 

POSTPARTUM HEMORRHAGE. 

Hemorrhage after labor or postpartum hemorrhage 
is one of the most serious complications with which the 
obstetrician and the obstetrical nurse has to deal. Its 
causes and the methods of preventing and managing 
it should be thoroughly understood by the nurse, for it is 
a condition that demands immediate action and gener- 
ally permits of no delay, such as would be caused by 
waiting for a physician. If a nurse is alone with the 
case she should always keep in mind the possibility of 
hemorrhage and make every preparation beforehand to 
meet it. Preparation is of the utmost importance. The 
sudden loss of a large quantity of blood is calculated to 
upset the most experienced. The well-grounded fear that 
a patient may die in a few moments unless effectual 
aid is given, calls not only for a clear head but also for 
well-trained, systematic, vigorous action. 

Causes of Hemorrhage. — Let us consider first the causes of 
postpartum hemorrhage. A comprehension of this subject 
will necessitate a short study of the mechanism by which 
hemorrhage is prevented in ordinary cases of normal labor. 
You will remember that when the after-birth separates 
from the uterus it carries along with it a part of the decidua 
(see page 63). The line of separation of the placenta 
passes through the middle of the decidua or changed 
uterine mucous membrane. In this plane there are 
numbers of bloodvessels and blood-sinuses which supply 
nourishment to the egg. Of course, many of these vessels 
are torn open by the separation of the placenta. The 
question is: "Why is there not always an alarming 



POSTPARTUM HEMORRHAGE 



173 



hemorrhage from these torn vessels? What is the mechan- 
ism by which these vessels are closed?" 

To answer these questions we must take into considera- 
tion the arrangement of the fibers of the uterine walls. 
In the unimpregnated uterus the muscle fibers cross 
each other and interlace in a very complicated system. 
During pregnancy these muscles not only enlarge and 
elongate, but also change their relation to each other so 
that they come to lie somewhat parallel with each other. 
As soon as the uterus is emptied the uterine muscle fibers 
not only contract but also immediately begin to assume 
the arrangement that existed before pregnancy. In this 
way, that is by a combination of prolonged contractions 
of the uterine muscle fibers and a resumption of their 
interlacing arrangements, the bloodvessels, passing in a 
tortuous manner through the uterine walls among the 
individual fibers, are so contracted that their caliber is 
nearly or entirely closed. This allows the formation of 
clots in the vessels which gradually organize and obliterate 
them. 

It is therefore by the action of the uterine muscles that 
postpartum hemorrhage is prevented. The continuous 
contraction and rapid rearrangement of the muscular 
fibers close the vessels so quickly and surely that ordi- 
narily only a few ounces of blood, and sometimes indeed 
only a few drams, escape after the birth of the placenta. 

Atonic Hemorrhage. — We can now understand how a 
failure in the contraction of the uterus may lead to bleed- 
ing. We may here use the term contraction to denote 
not only the contraction of the individual fibers, but 
their rearrangement. This uncontracted condition of 
the uterus is often called atony of the uterus, which 
means, of course, its lack of power; and a hemorrhage 
resulting from such atony is called atonic bleeding. The 
bleeding goes on continuously from the unclosed vessels 
of the uterus, and chiefly from those of the placental site. 
The blood may flow away almost continuously through 
the dilated cervix, or as usually happens, the cervix may 



174 



LABOR 



contract sufficiently to partly close for a moment the exit 
from the uterus. In this case the blood will accumulate 
inside the womb and distend it until it may become 
nearly as large as it was before the expulsion of the child. 
A contraction will then force out this enormous mass of 
blood from the uterus and vagina to the outside, when the 
process of filling and emptying the uterus will again be re- 
peated until the patient dies from the loss of blood. As a 
rule the hemorrhage, shown by the appearance of blood 
on the outside, is more or less intermittent, corresponding 
to the contractions of the uterus which force out the 
blood. If the hand is held over the abdomen in such 
a case of hemorrhage it will be noticed that the uterus 
becomes large and soft and frequently indistinguishable. 
No blood will then escape from the vulva until by rub- 
bing with the hand the uterus contracts and becomes 
hard and a gush of blood appears. When it again relaxes, 
a sign that the blood is filling up the uterus, the external 
hemorrhage ceases. These observations show us that it is 
not the appearance of the blood on the outside that we 
need fear. Massaging of the uterus or perhaps a movement 
of the patient causes a uterine contraction and expulsion 
of the blood, and this frightens the patient and perhaps 
leads her to think that the rubbing makes her bleed and 
therefore is dangerous. We know that the blood that is 
collected in the uterus is already on the outside of the 
bloodvessels of the patient and is no longer of any value 
to her. It is only a source of danger in the uterus, for it 
prevents the firm uterine contractions, hence it is much 
better outside the body. As we shall learn in a moment, 
when we come to speak of the management of hemorrhage 
we seek to control the escape of blood from the blood- 
vessels and not the retention in the body of the blood 
already lost to the patient. 

Weakness or atony of the uterus is more apt to occur 
after a long and severe labor, or in cases where the uterus 
has been unusually distended, for example in twin preg- 
nancies or hydramnion. It is at times the result of a 



POSTPARTUM HEMORRHAGE 



175 



premature expression of the placenta. After the severe 
contractions required to expel the child it would seem 
natural that an interval of rest were necessary before 
the final stage of labor. Interference which deprives 
the uterine muscles of this interval of rest is often a 
cause of subsequent inefficient contraction and resulting 
hemorrhage. 

Hemorrhage from Partial Detachment of the Placenta. — 

Another important factor in preventing efficient uterine 
contraction and producing hemorrhage is the presence in 
it of a more or less detached placenta. Until the placenta 
begins to separate there is, of course, no hemorrhage 
from the placental site. When a part of the placenta 
remains adherent to the uterus it may prevent a thorough 
contraction of the uterine muscle and thus give rise to 
bleeding from the denuded portion of the uterine wall. 
This may happen whether the entire or partially separated 
placenta remains in the uterus or whether the separated 
portion has been expelled, leaving a piece of the adherent 
placenta. 

We therefore have two classes of cases, one where there 
is a partial separation of the placenta and the other 
where there is complete separation of the placenta. When 
there is partial separation of the placenta the entire 
after-birth may remain in the obstetrical canal or the 
separated portion may be expelled. 

Traumatic Hemorrhage. — Postpartum hemorrhage may 
also be due to tears in the obstetrical canal, generally 
in the cervix or the vagina. A large tear, sufficient to 
cause considerable or serious hemorrhage, rarely occurs 
in uncomplicated, spontaneous labor, but is due gener- 
ally to operative interference. It consequently does not 
interest the nurse so much as atonic hemorrhage, since she 
is never alone and obliged to assume the responsibility 
of these cases. It will consequently be necessary to men- 
tion only the cause of the hemorrhage and perhaps to 
point out how it may be distinguished from that due to 
atony of the uterus. Hemorrhage due to tears or lacera- 



176 



LABOR 



tions is continuous, while in atonic bleeding the external 
hemorrhage is intermittent or ceases, at least in part, 
after contractions of the uterus. 

Hemorrhage from Deficient Coagulability of the Blood. — 

Still another cause of postpartum hemorrhage is occasion- 
ally found in the altered condition of the blood. Unless 
the blood possesses a certain power to coagulate or clot 
the stoppage of hemorrhage from a ruptured vessel is 
impossible. Blood varies in its coagulative ability. There 
are some people whose blood has very little tendency to 
clot, and these individuals bleed very freely whenever the 
smallest vessels are ruptured. A slight cut, pulling of a 
tooth, or blowing of the nose may be followed by a very 
severe bleeding. These people are often called "bleeders." 
It is evident that a woman who has this bleeding tendency 
would be in more danger from hemorrhage after labor 
than a woman not so affected. In some kinds of disease 
also the coagulability of the blood is diminished. This is 
true of malaria for example. If the nurse has reason to 
think, from the past history of the patient, that she 
is liable to attacks of frequent and severe hemorrhage, 
she should, of course, take unusual care to prevent and 
control hemorrhage after labor. 

Inversion of the Uterus. — One other cause of postpartum 
hemorrhage is the occurrence of a serious accident known 
as inversion of the uterus. This is a turning inside out 
of the womb, due to traction upon the placenta or some- 
times to pressure made in the effort to expel the placenta, 
or sometimes it happens spontaneously while the cervix 
is still open so as to admit of the passage through it of the 
base of the organ. It is, of course, a very serious accident 
not only on account of the hemorrhage but on account 
of the shock. It is very rare, and is only mentioned as 
one of the possibilities which the nurse has to bear in 
mind. (Fig. 72.) 

Prevention of Postpartum Hemorrhage. — The prevention 
of postpartum hemorrhage is mainly, so far as the nurse 
is concerned, its prompt and vigorous treatment at the 



POSTPARTUM HEMORRHAGE 



177 



instant of its appearance. As was said above, hemorrhage 
might be due to the improper expression or extraction 
of the placenta. As a nurse, however, should never 
attempt to extract the placenta, unless such a measure 
were indicated by hemorrhage, it is not necessary to 
allude further to this point. 

Fig. 72 




Partial or incomplete inversion of the uterus. The placenta is still 
attached and hemorrhage may not occur until its separation begins. 



Removal of the Partly Adherent Placenta. — In consider- 
ing the treatment of postpartum hemorrhage we must take 
into account the question of the presence or the absence 
of the placenta in the uterus. If bleeding occurs before 
the placenta is born we have a partly adherent placenta 
which prevents an efficient contraction of the uterus; 
hence it is necessary to get rid of the after-birth in 
order to stop the bleeding. 
12 



178 



LABOR 



We must, therefore, consider the methods of extracting 
or expelling the placenta. Three may be mentioned: 
traction on the cord, Crede expression, and manual sepa- 
ration. The first method, that of removing the after- 
birth by pulling on the cord, should never be practised. 
Unless the placenta is very tough it might tear in two 
and a portion be left behind in the uterus. If it is very 
tough and firmly adherent the uterus might be inverted 
by forcible pulling. 

Fig. 73 




Crede's method of expressing the placenta. (Bumm.) 



Expression of the Placenta. — Expression is the proper 
technique to employ in removing the placenta. It is 



POSTPARTUM HEMORRHAGE 179 



called the Crede method because it was described and 
advocated by the great German obstetrician who taught 
many years in Leipzig. It is also and better called 
the Dublin method, because it was practised in the 
Rotunda Hospital in Dublin even long before the time of 
Crede. It is performed in the following way : The fundus 
of the uterus is grasped as well as possible in the hand 
through the abdominal walls, the separated fingers pass- 
ing behind and the thumb in front. If the nurse is on 
the right side of the patient she grasps the uterus with 
the left hand. Before beginning the manipulation the 
uterus has been rubbed to secure a contraction. As soon 
as it begins to harden the expression begins. Having 
grasped the uterus it is squeezed in the hand, at the 
same time pressing down in the axis of the outlet 
of the pelvis. A firm grasp and an energetic pushing 
movement must be continued for one or two minutes 
or until the placenta appears. If this measure does not 
succeed and the hemorrhage is very great the nurse may 
repeat the manipulation, using both hands. She must 
remember, however, that the expression of the placenta 
is to be done only when there is great danger of bleeding. 
A slight hemorrhage or one that is easily controlled by 
a little rubbing over the uterus is not an indication for 
interference. 

Manual Removal of the Placenta. — The third method 
of removing the placenta by the introduction of the 
entire hand into the uterus and peeling it off from the 
surface is one that is required very rarely, perhaps two 
or three times in a thousand cases, and should never 
be done by the nurse except in the most extreme cases. 
It is a dangerous manipulation, because the patient is 
subjected to very great danger of infection by the intro- 
duction of the hand into the raw, absorbent uterus. As 
there is probably not one case in ten thousand where 
this manipulation will be required of a nurse it need 
not be further described. In practically all cases where 
the nurse is alone with the patient, where the removal of 



180 



LABOR 



the placenta is necessary, the Crede expression properly 
performed will succeed. 

When the bleeding begins before the expulsion of the 
placenta the nurse should at once tie the cord and separate 
the child if it still remains attached. She should then rub 
the uterus through the abdomen somewhat vigorously 
to stimulate the uterine contractions. If the bleeding 
continues moderately the massage should be persisted 
in. If the bleeding becomes more serious she should 
then try to secure a uterine contraction by rubbing and 
then grasping the uterus and express the placenta. If she 
should not succeed at first her efforts may, however, 
produce sufficient contraction to control the hemorrhage. 
If not, and the hemorrhage becomes alarming, expression 
with both hands must be made. Afterward the steady, 
persistent massage of the uterus through the abdominal 
wall to keep up the contraction, aided by other measures 
about to be described, will be indicated. 

A question may arise concerning the measures to take 
in case a portion of the placenta remains in the uterus. 
When there is no hemorrhage this adherent placenta will 
cause no trouble and must be let alone. It will seldom 
happen if the third stage of labor is properly managed. 
Probably it will never be a source of danger so great that 
it will not permit the calling of a physician. 

Management of Atonic Hemorrhage. — When we now 
come to consider the management of hemorrhages that 
occur after the expulsion of the placenta we must mention 
the stimulation of the uterine contraction by massage 
of the uterus through the abdomen, by hot- water douche, 
and by the administration of pituitary extract or ergot, 
and the combating of the serious and dangerous symp- 
toms by attending to the position of the patient, by 
bandaging the extremities, and by the hypodermic injec- 
tion of salt solution. 

Massage. — Attention has been called already to the 
importance of keeping the hand on the abdomen after 
labor for the purpose of studying its condition, and 



POSTPARTUM HEMORRHAGE 



181 



perhaps exerting a slight stimulating effect on the uterus. 
In order to stimulate efficient uterine contractions in 
case of hemorrhage, vigorous manipulation must be made. 
The hand should move up and down and back and forth 
across the uterus, pressing the fingers behind the uterus 
so as to grasp it as in the Crede expression. Squeezing 
movements as well as rubbing with the ends of the fingers 
should be employed. These manipulations must not be 
discontinued as soon as the hemorrhage stops, but should 
be employed for twenty to thirty minutes to prevent 
relaxation. A supplement to the hand in the stimulation 
of the skin may be had in cold. A piece of ice or a cold, 
wet towel placed over the lower abdomen may help at 
first in starting the uterine contractions. 

Hot Douche. — The next and perhaps the most impor- 
tant measure against hemorrhage is the hot vaginal 
douche. Sometimes an intra-uterine douche is given, 
but in most cases the vaginal douche is efficient and 
is therefore recommended to nurses. It is immaterial 
whether sterile water or some weak antiseptic substance 
be employed. As a large quantity may be needed, per- 
haps gallons, it is best that the ordinary salt solution 
be used. The main thing is that the douche should be hot. 
It should have a temperature of 120°. Warm water from 
100° to 110° has only a relaxing effect, while water of 
120° is a powerful stimulant to the contracting fibers of 
the bloodvessels and to the involuntary uterine muscles. 

It is very essential that the douche should be given 
promptly. It should always be prepared before the com- 
pletion of labor. The bag or receptacle is filled and all 
that is needed is to pull the patient over to the edge of the 
bed, turn up the edge of the rubber draw sheet, introduce 
the tube, and let the water run. If the bed has been pre- 
pared as before described and the douche prepared the 
irrigation should begin within twenty seconds from the 
beginning of the hemorrhage. Provision must be made 
to keep up the flow. Someone must assist in filling the 
irrigator. It will then be possible for the nurse, sitting 



182 



LABOR 



by the bed, to support the patient, whose right hip and 
thigh lie partially over the edge of the bed with the foot 

Fig. 74 



MP 




Giving a hot vaginal douche for p. p. hemorrhage. The patient lies 
on the right edge of the bed with her right leg supported on a stool. 
The nurse is separating the labia with the thumb and fingers of her left 
hand and is about to insert the douche point which she holds in her right 
hand. 



resting on a chair or stool, and at the same time with her 
left hand to keep up the massage over the uterus. 



POSTPARTUM HEMORRHAGE 



183 



It should be repeated and emphasized that the douche 
should not be stopped as soon as the water begins to 
come away clear. A return of the hemorrhage is always to 
be feared and a cessation of the bleeding fifteen minutes 
is necessary before one is justified in withdrawing the 
stimulus of the douche. It may be continued an hour 
or more. When it is given as advised the patient is not 
at all disturbed and may even go to sleep while the water 
is running. 

Ergot. — The third agent to excite and strengthen the 
uterine contractions is ergot. In moderate cases of relax- 
ation of the uterus it is given by the mouth. In serious 
cases of hemorrhage, such as we are here considering, 
it should be given under the skin. For hypodermic use 
a less irritating preparation than the pharmacopeal fluid 
extract should be employed. Such preparations are sup- 
plied by different manufacturers. The fluidextract or 
its substitute may be given in doses of 20 to 60 minims, 
according to the urgency of the case, and repeated in ten 
to fifteen minutes. 

Pituitary Extract. — Recently the extract of the pituitary 
gland of the sheep has been used to excite uterine con- 
tractions. It is put on the market by the manufacturers 
in ampoules, each containing 1 c.c, corresponding to 
0.2 gram of the extract, which is the average dose. It 
is given intramuscularly and used both during labor and 
in atony of the uterus after labor. The indications for 
its use in postpartum hemorrhage are the same as those 
for ergot, with which it can often be combined with advan- 
tage, as its action is more rapid if not so permanent. 

Summary of Treatment of Postpartum Hemorrhage. — As 
with the douche, so the hypodermic injections of ergot 
and pituitary extract have been prepared beforehand in 
order that no time may be lost. The order of proceeding 
will be as follows: If a sudden hemorrhage appears the 
patient is drawn to the edge of the bed and the douche 
begun; with the left hand the nurse manipulates the 
uterus through the abdominal walls, with the right hand 



184 



LABOR 



she takes her syringe and injects the pituitary extract or 
ergot. Then she is at liberty to supervise the filling of 
the douche bag or can, and to watch the patient and the 
effect of her measures. There should be no confusion. 
The patient need not be alarmed. The nurse knows 
what is to be done and has confidence in herself because 
of this knowledge. Under no circumstances should she 
change from this routine and try a number of measures one 
after another. But three measures have been described, 
and these are all that are necessary if efficiently employed. 
If the physician be present he may pack the uterus with 
sterile gauze. This is an operation which a nurse would 
never be expected to perform, and therefore it is not 
necessary to describe it in detail. Many other things 
have been advised from time to time, but none are as 
good or as safe as these, and the importance of persistent 
action along a definite line is so great that it seems best 
not to introduce any complication by recommending 
other agents. 

Combating After-effects of Hemorrhage. — In a severe 
hemorrhage the patient becomes dizzy and faint, and per- 
haps nauseated, has difficulty in breathing, perhaps hears a 
buzzing in her ears and, of course, looks very pale. These 
symptoms are due to lack of blood in the brain, which 
suffers very promptly upon the failure of the circulation. 
The pulse is very weak. The heart requires a certain 
amount of fluid in order to contract properly. The char- 
acter of the circulating fluid is of less importance than 
the quantity. If two pounds of blood be drawn from the 
body suddenly there is greater distress than if twice 
that quantity were drawn slowly in twenty-four hours. 
In the latter case the quantity is made up by the pas- 
sage into the vessels of the fluid outside of them. 

In order to combat the symptoms and dangers due 
to the hemorrhage it is necessary to make use of all 
the blood that remains and to inject into the body a 
substitute for the lost blood. We make use of the 
remaining blood by putting the patient in such a position 



POSTPARTUM HEMORRHAGE 



185 



that the blood will flow to and remain in the centre 
which controls the vital processes, namely, the head. 
The head is lowered and the body elevated. The pillow is 
removed and the foot of the bed raised. In extreme cases 
this may be supplemented by bandaging the extremities. 
A nurse, when she is alone, would, of course, never leave 
her position at the side of the patient where she is giving 
the douche and kneading the uterus. She may, however, 
be called upon by her physician to do this. For the pur- 
pose of bandaging, a sheet may be torn into strips three 
or four inches wide, quickly rolled and applied firmly, 
beginning at the toes and passing up as far as possible 
on the thighs. 

HypodermocJysis. — The lost blood is substituted by the 
normal salt solution. This may be best administered by 
means of a fountain syringe or by the use of a reservoir 
with a tube, employing the principle of gravity. Into the 
further end of the rubber tube is placed the large stem of a 
glass Y, which is to divide the stream. To the smaller limbs 
of this Y is attached smaller pieces of rubber tubing a half 
a yard long, which carry large hypodermic needles. With 
this apparatus the solution may be introduced into two 
separate parts of the body at the same time and with 
considerable rapidity. The parts best adapted to receive 
the saline solution are the fronts of the thighs. The method 
of preparing the solution and using it is as follows : 

Unless the physician or nurse is provided with sterile 
salt tablets ordinary clean table salt will answer. There 
being no exact measure at hand, let her take a medium- 
sized teaspoon, fill it with salt lightly, not packing the 
salt, and then with a straight edge, as, for example, the 
edge of a knife-blade, strike off the extra salt. This level 
teaspoonful of salt is sufficient for one pint of water. The 
water used should have been boiled. Into the water the 
salt is placed and then boiled again in order that the solu- 
tion may be perfectly sterile. If a great quantity of the 
solution is needed, of course double the quantity of salt 
and water will be employed. If the nurse anticipates the 



186 



LABOR 



use of the solution she would better prepare it of double 
strength beforehand. It may then be dilated with warm 
water when needed for use. The apparatus for the intro- 
duction of the salt solution should be put together and 
wrapped in a towel or piece of gauze and put into a kettle 
and boiled, when it is ready to receive the solution. 



Fig. 75 




Hypodermoclysis. Injecting normal salt solution into the thighs. 



The proper temperature of the solution is about 98° 
to 99°. A variation of 3° or 4° is, however, unimportant. 



DYSTOCIA 



187 



Since the solution cools during the process of introduction 
a little hot solution should be added from time to time 
or a flame placed under the receptacle. To determine the 
temperature a sterilized thermometer should be on hand. 
The thermometer included in a glass connecting link that 
can be inserted in the tube is desirable. One may estimate 
the temperature fairly accurately by allowing the solution 
to flow from a needle over the back of the hand. Every- 
thing being ready, the skin in the region of the proposed 
puncture is disinfected and the needles introduced. They 
should not pass too close to the skin, neither should they 
pass too deeply into the muscles. Before introducing them 
the receptacle is raised and the solution allowed to flow 
until the tube and needles are full of the warm solution. 
The rapidity of the flow will depend partly upon the height 
of the receptacle, partly upon the nature of the tissue into 
which the solution is introduced, and partly upon the 
massage manipulations which help in the absorption of 
the fluid. Ordinarily one to two pints can be injected 
in fifteen minutes. 

Long before the injection of this amount is completed 
its effects are apparent. The pulse improves, the patient 
breathes more easily, and the terrible feeling of thirst 
is allayed. The salt solution, moreover, has not only a 
temporary but also a permanent effect. Patients recover 
much more rapidly and without complications after its 
use. While the nurse will hardly ever, and perhaps never, 
be called upon to use the salt solution upon her own 
responsibility, she should understand the technique of 
its preparation and administration so that she may pre- 
pare it and use it properly when ordered by the physician. 



DYSTOCIA. 

Definition. — Dystocia, or abnormal labor, occurs when 
there is some abnormality in the forces of labor, in the 
passages, in the passenger, or in the mechanism of labor. 



188 



LABOR 



Likewise any accident occurring during labor is a cause 
of dystocia. 

According to this definition, postpartum hemorrhage 
(see p. 172), separation of the normally seated placenta 
(see p. 95), and other conditions already discussed are 
cases of dystocia. Although its management is always 
the business of the physician, it is desirable that the nurse 
should have a brief outline of the subject. 

Dystocia from Abnormal Forces. — The contractions 
of the uterus may be excessive or weak. Excessive con- 
tractions may be too strong, they may last too long, or 
they may be too frequent. When the contractions come 
so fast and last so long that the resting periods are no 
longer than the contracting periods the contractions 
are pathological. When the contractions are practically 
continuous they are said to be tetanic. We shall not 
discuss the causes of excessive contractions except to 
say that ergot will produce them. The most important 
result is the injury or death of the child by the compres- 
sion of the placenta and the uterine vessels. Precipitate 
labor may result and also rupture of the uterus. The 
treatment is generally the administration of sedatives or 
anesthetics. 

Weak contractions lead to inertia or atony of the uterus. 
The contractions may be less in intensity, shorter, or less 
frequent. This condition may be primary at the beginning 
of labor, or secondary, occurring during labor. In the 
latter case it may be due to exhaustion following excessive 
contractions. The chief danger is the exhaustion of the 
mother and in the third stage of labor atonic hemorrhage. 
The treatment depends upon the cause of the atony and 
the condition of the patient. 

Dystocia from Abnormal Passages. — Contracted and 
other deformed pelves (see p. 34) may interfere with 
or absolutely prevent the passage of the child. The 
treatment may be delivery by forceps or by enlarging 
the pelvis or by a delivery through a cesarean section. 
Ovarian tumors and tumors of the uterus may prevent 



DYSTOCIA 



189 



the delivery and require removal of the obstruction or of 
the child. 

Fetal Dystocia. — Dystocia from Abnormalities in the 
Passenger. — Occasionally a child is too big to pass through 
even a normal pelvis. This may be due to retardation 
of the labor or to hereditary influences. The case must 
be managed like one of contracted pelvis. Sometimes 
deformities of the fetus, like fetal tumors, hydrocephalus, 
etc., make labor abnormal and require interference. 

Twins. — In this connection we may speak of multiple 
pregnancies in which the labors are frequently abnormal. 
Twins occur once in about ninety pregnancies and triplets 
once in about eight thousand. Heredity is a factor in the 
causation; a history of twins on either the mother's or 
father's side is nearly always found. They may originate 
in different ways. Two Graafian follicles may rupture 
simultaneously and both ova be fertilized, or there may 
be two ova in one follicle. Then one ovum may have 
two nuclei. Finally after the fertilization of an ordinary 
ovum the nucleus may divide completely and each half 
develop as a separate egg. When the twins are from the 
same egg both are of the same sex. When they are from 
different eggs they may be of different sexes. When they 
are from one egg there is often a connection between their 
placental vessels. In this case after the birth of the first 
child if the placental end of the cord were not tied before 
cutting the second child might bleed to death. 

The great distention of the uterus may interfere with 
its normal contractions. Sometimes the fetuses become 
locked. After the birth of the first child the delivery of 
the second may be delayed. Finally postpartum hemor- 
rhage is always to be feared. 

Short Cord. — Rarely the cord is so short that it does 
not allow the escape of the child from the vagina. More 
frequently the cord is rather long but coiled several times 
around the neck of the child, so that it also prevents the 
birth of the child. Ordinarily one or two coils around the 
neck causes no disturbance in the labor. 



190 



LABOR 



Prolapse of the Cord. — One of the most serious kinds 
of fetal dystocia is prolapse of the cord, which occurs 
about once in one hundred and fifty labors. It is more 
often found in cross-presentations of the fetus and in 
labors in flat pelves. As it generally results in death of 
the child unless it is properly managed it is- important 
to make an early diagnosis. Unfortunately without an 
internal examination a diagnosis can hardly be made before 
the cord appears at the vulva. Any marked irregularities 
in the fetal heart tones would raise a suspicion of pressure 
on the cord. Hence this is another reason why the nurse 
should watch the heart tones carefully. Should the cord 
present at the vulva, or should there be other reason to 
suspect a prolapse of the cord while waiting for the physi- 
cian, the patient should first take the knee-chest position 
for three or four minutes and then lie with the hips much 
elevated so as to favor the reposition of the cord by gravity. 

Dystocia from Abnormal Mechanism of Labor. — Here we 
have abnormalities in one or more of the steps of labor. 
We may have abnormal presentation at the inlet. Instead 
of the vertex or the occiput the brow or face or the side 
of the head may present. In some cases the breech or 
foot or shoulder may be in advance. In the excavation 
the head may not undergo proper internal rotation. If 
no rotation takes place and the occiput remains to one 
side the condition is called deep transverse arrest. If the 
occiput rotates backward we have the so-called occiput 
posterior, a condition that makes spontaneous labor slow 
and difficult. Sometimes there is a compound presenta- 
tion such as an arm or leg with the head. When the 
progress of labor is not satisfactory some abnormality in 
the mechanism is to be suspected. 

Dystocia Due to Accidents. — Eclampsia, placenta 
previa, postpartum hemorrhage, separation of the nor- 
mally seated placenta, and inversion of the uterus, which 
have already been considered, belong here. Another 
pathological condition during the third stage is the adher- 
ence of the placenta and membranes. Partial adherence 



OBSTETRICAL OPERATIONS 



191 



with resulting hemorrhage has been discussed (see p. 175). 
Complete adherence is generally attended with no hemor- 
rhage and need not disturb the nurse. She watches the 
patient carefully and waits for the physician. 

Rupture of the Uterus. — This accident is fortunately 
very rare, occurring only once in about one thousand 
labors. The tear is generally found in the lower uterine 
segment at the junction of the cervix and body. Spon- 
taneous rupture follows excessive contractions in an 
obstructed labor, for example in a case of transverse 
presentation. The lower dilating segment becomes very 
thin and finally gives way. Artificial rupture results 
from some operation like turning, forceps, etc. The imme- 
diate results of rupture are pain, shock, cessation of uterine 
contractions, hemorrhage, internal and external, and dis- 
appearance of the fetus. Practically all children die, and 
in spite of treatment about 50 to 70 per cent, of the 
mothers. It is important to know that this terrible acci- 
dent is possible in a very hard labor, especially when the 
contractions are very severe. 

Vulvar and Perineal Lacerations. — The way for the nurse 
to prevent laceration has been described. The physician 
will generally repair them after the expulsion of the 
placenta if the patient is in condition. Sometimes small 
tears are repaired while waiting for the placenta to come 
away. The nurse will be called on to assist in the opera- 
tion or in the anesthesia. Preparation must be made 
while waiting for the third stage unless everything was 
in readiness beforehand. 



OBSTETRICAL OPERATIONS. 

Frequency. — If all kinds of operations are considered, 
including repairs of lacerations, they probably occur in 
one-fourth to one-third of all cases of labor. This fact 
indicates the importance of the subject. The nurse must 
prepare for them and assist at them. It is necessary, 



192 



LABOR 



therefore, that she knows their object and general character 
and the names and uses of the instruments employed. 

The following classification of obstetrical operations 
may be of value in furnishing a general oversight of the 
subject: 

Preparatory Operations. 

Induction of labor and abortion. 
Dilating: cervix (metreurysis). 
Vagina and vulva (colpeurysis). 
Pelvis (symphyseotomy and hebosteotomy. 
Improving position and attitude : turning, changing 
position and presentation, replacing parts. 
Delivery Operations. 
Expression; Kristeller or expressing body; Hofmeier, 

expressing head. 
Forceps: low, middle, and high. 
Manual extraction. 

Cesarean section; classical, Porro; extraperitoneal, 
vaginal. 

Embryotomy; perforation and cranioclasis, decapita- 
tion. 

Third Stage Operations. 
Manual extraction, Crede expression, expression 
from vagina. 
Reparatory Operations. 

Cervix, vagina, vulva, perineum. 
Accessory Operations. 

Douche; vaginal and intra-uterine. 
Hypodermoclysis. 
Preparation. — The more serious preparatory, delivery, and 
reparatory operations should be done in a hospital when 
one is accessible and the transfer of the patient is possible. 
When it is necessary to operate at home the best possible 
preparation should be made. The largest, warmest, best 
lighted, and most convenient room in the house should be 
chosen. Frequently the kitchen or dining-room possesses 
these qualifications. Rugs should be removed from the floor 
and a carpet should be covered with an oil-cloth or with 



OBSTETRICAL OPERATIONS 



193 



sheets. In daytime light is secured from windows, which 
may be rendered translucent when necessary by a tem- 
porary sash curtain or by coating the glass with soapsuds. 
The table is placed so that the light falls most advantage- 
ously on the genitalia. At night if the house has electric 
lighting the bulb may be held or hung so as to give an 
ideal illumination. Generally an extra powerful lamp 
may be secured. If only an overhead light is available, 
as with a gas jet, the table should be placed so that the 
light comes from behind the operator at an angle of about 
60 degrees. Lamps can rarely be placed behind the operator 
in good position, and he sometimes uses a head mirror 
to reflect the light from the lamp placed safely at the side. 

Fig. 76 




Kitchen table arranged for an operating table. The sheet on the table 
is to be used as a leg-holder. 

For most operations the ordinary kitchen table makes 
a very satisfactory operating table. As the patient is 
13 



194 



LABOR 



generally in the lithotomy position it is long enough. 
It should be covered with a blanket and a clean sheet. 
A rubber or oil-cloth sheet is laid on the end of the table 
and drawn into a pail or jar for drainage. 

Slight repair operations may be made with the patient 
in bed, her hips being elevated on the douche-pan, or 
she may be turned across the bed. More extensive repairs 
and all delivery operations should be done on a table. 

Behind the table is a plain chair for the operator. At 
his right hand is a large table or two small ones, covered 
with a clean sheet to hold the instruments, basins with 
solutions, pitchers, sponges, sheets, towels, etc. At one 
side is the irrigator hung up and filled ready for use 
before the patient is brought to the table. A long sheet 
rolled diagonally, to be used as a leg holder, is placed on 
the operating table. 

Most operations are better made under anesthesia. 
Although the services of a physician or a trained anes- 
thetist should always be secured if possible, yet some- 
times in an emergency the nurse must give the anesthetic. 
The administration of an anesthetic to produce complete 
anesthesia is more difficult and involves greater responsi- 
bility than the use of a little ether during contractions 
to dull the pain of labor. As ether is always much safer 
than chloroform, probably a physician would choose it 
if the nurse is the anesthetist. It is to be given in the 
way already described, but continuously. The patient 
may pass through stages of exhilaration before she is 
under the influence of the drug. This part of the process 
is, however, watched by the physician. Later when it is 
necessary to hold the patient unconscious she must care- 
fully observe the pulse and respiration as well as the color 
of the face. A nurse should take every opportunity of 
watching the administration of anesthetics and particu- 
larly learn how to hold the jaw so as to keep the tongue 
from dropping back and impeding respiration. 

Induction of Abortion. — This operation is made only in 
those extreme cases of pregnancy complicated by serious 



OBSTETRICAL OPERATIONS 



195 



heart disease, kidney disease, tuberculosis, or similar 
affection, when the operation is necessary to save the life 
of the mother. When the operation is not absolutely 
necessary it ceases to be legitimate; then it is not a 
therapeutic but a criminal abortion. It is forbidden 
by law under penalty of imprisonment. If the patient 
should die as the result of a criminal abortion the operator 
is guilty of murder. Hence to avoid any suspicion every 
physician will consult with a reputable colleague before 
deciding upon making a therapeutic abortion. He will 
also secure the consent in writing of the patient and if 
possible of her husband or next of kin. The operation 
can generally be done in a hospital. 

Before the fourteenth week the operation can be done 
at one sitting by rapid dilatation and curettement. 
The instruments needed are a branched dilator or a set 
of Hegar's dilators, a curette with a flexible shank, two 
vaginal retractors, two volsellum forceps, and a dressing 
forceps for eventual packing. 

Between the fourteenth and twenty-eighth week it is 
generally necessary, on account of the size of the fetus, 
to make a preliminary dilatation with tents, followed after 
twelve hours with further dilatation and curettement. It 
is necessary that the tents should be sterile. They cannot 
be boiled, of course, because they swell upon being brought 
in contact with a watery fluid. They can be put into and 
kept in strong alcohol after they have been sterilized with 
dry heat. 

To introduce the tent anesthesia is not generally 
necessary. The patient must be shaved and otherwise 
thoroughly prepared. The instruments needed are the 
vaginal retractors, a volsellum forceps to grasp the cervix, 
a small dilator for preliminary dilatation, and a dressing 
forceps to hold the tents. One or more are introduced 
according to the size of the tents and the amount of 
dilatation of the cervix. Frequently a small vaginal 
packing of sterile or antiseptic gauze is used to help keep 
the tents in place. After about twelve hours the patient 



196 



LABOR 



is anesthetized and the tents removed, the cervix further 
dilated with instruments or digitally, and then the fetus 
and placenta are removed. This is accomplished with the 
fingers alone or with the fingers and curette combined. 
Packing for postpartum hemorrhage or to help the con- 
tractions of the uterus must be in readiness; likewise ergot 
and a hot douche. 

Sterile petrolatum or oil should always be on hand 
to lubricate the dilators and the tents. 



Fig. 77 




Tents and instruments for introducing them to induce abortion. 



Induction of Labor. — Labor may be induced because 
of some disease of the mother, like heart disease, kidney 
disease, consumption, or threatened eclampsia, which 
threatens her life if pregnancy continues. Here the opera- 
tion must be done when the mother's condition requires 
it, although in general it is postponed as long as possible 
on account of the child. Sometimes the operation is done 
because the pelvis is too small to admit the passage of a 
full-term child while it is big enough for a child of thirty- 
five to thirty-seven weeks. Here the labor is never 



OBSTETRICAL OPERATIONS 



197 



induced before the thirty-fifth week because a younger 
child has too poor a chance of living. 

Preparations for this operation include not only the 
usual preparation of the mother but provision for the 
child. It must be handled with care, and especially must 
it be protected from chilling. Possibly an incubator should 
be provided as well as a tank of oxygen, and the nurse 
should be ready to care for the child as directed in the 
discussion on the management of premature infants 
(see p. 334). 

One method of inducing labor is the introduction of 
one or more bougies into the uterus. The hollow bougies 
with the stylets are sterilized by boiling. The other 
instruments needed are a vaginal retractor, a volsellum 
forceps, and a dressing forceps. No anesthetic is necessary. 
The operation is done with the patient in the lithotomy 
position on a table. Solutions and sponges are, of course, 
in readiness as well as gauze for packing the vagina. 

Labor rarely starts very promptly after the use of the 
bougies. If regular pains do not come on in the course 
of eighteen hours the physician removes the bougies, 
cleans the vagina thoroughly, and introduces others. 
When labor is well started the bougies are permanently 
removed. Sometimes when there is a large amount of 
liquor amnii or when the patient is suffering from dyspnea 
labor is induced by simply rupturing the membranes. 
This may require no instruments, the physician simply 
breaking the membrane with the examining finger or per- 
haps with a rather sharp pointed blade of an artery forceps. 

The most common method of inducing labor is the 
dilatation of the cervix with a bag. Such a bag is called 
a metreurynter, and the process is metreurysis. The 
best kind of a metreurynter is non-elastic, made of a 
strong tissue which is vulcanized. It has a tube for 
filling, by means of which traction can be made on the 
bag. The Voorhees bags, which are conical in form 
and come in different sizes, in sets of four or more, are 
most used in this country. 



198 



LABOR 



The bags are sterilized by boiling. For introduction 
there are needed two vaginal retractors, two volsellum 
forceps, one dressing forceps to hold the bag, one or more 
dilators, sponges and solutions, a bulb syringe for rilling 
the bag, and a ligature for tying the tube. A nervous 
and sensitive patient may need an anesthetic. The 



Fig. 78 




Instruments for metreurysis. One Vorhees bag is held in the forceps 
ready for introduction. 



sterile bags and syringe, contained in a basin or pitcher 
of sterile water, are held near the vulva on the right side 
of the operator. After grasping the cervix and dilating, 
if necessary, he punctures the membranes with the end of 
the dressing forceps and then carries the folded bag with 
the forceps through the cervix into the amniotic cavity. 
Sometimes the membranes are not ruptured and the bag is 



OBSTETRICAL OPERATIONS 199 



inserted into the lower part of the uterus by pushing up 
the membrane. The physician then removes the vaginal 
retractors and, introducing the left half hand into the 
vagina, he holds the bag in place while he fills it with 
the bulb syringe worked with his right hand. When it is 
full he ties the tube and pushes it up into the vagina, 
retaining it there with gauze packing. Or if traction 
on the tube is desirable the tube is left protruding from 
the vulva. 

Labor starts more promptly after the introduction 
of the bag than after the bougie. There are generally 
some contractions at once, which gradually cease. After 
a few hours they recommence and continue as genuine 
labor pains. Occasionally the first contractions continue 
and develop into regular labor. When it becomes neces- 
sary to hasten the labor the physician may make inter- 
mittent traction on the tube. The nurse is frequently 
entrusted with this duty. 

Should labor proceed very vigorously for some time 
and then stop or become much weakened the nurse may 
suspect that the bag has escaped from the cervix and lies 
in the vagina. She may determine the condition by gentle 
traction on the tube if that has been left protruding 
from the vagina. She should notify the physician in any 
case of the change in the character of the pains. 

Dilatation of the Cervix. — The objects of the various 
operations for dilating the cervix are to induce labor, 
to hasten labor, and to prepare for delivery operations. 
Metreurysis, or bag dilatation, which has just been 
described, is the chief method used for inducing labor. 
It may also be used for hastening labor and also to 
prepare the cervix for delivery operations. Here other 
methods which are more rapid are generally employed. 
Especially for accouchement force, i. e., rapid, forcible 
emptying of the uterus. These are manual or digital 
dilatation, the use of metal dilators, and incisions. 

Digital or manual dilatation is done with the fingers 
of one hand or with two hands. The patient is thoroughly 



200 



LABOR, 



prepared, anesthetized, and on the table. All preparations 
for the following delivery are first made. No instruments 
are needed, but the proper solutions and sponges must be 
in readiness. The physician generally begins with one 
hand with the so-called Harris method, and after dilating 
to the size of the fist he then employs both hands in the 
Edgar method. 

Metal dilators are rarely used in this country for com- 
plete dilatation, but only at the beginning, to provide 
for the introduction of a finger or a bag. The Bossi 
dilator, sometimes used in Italy and Germany, is a power- 
ful instrument, but feared on account of the tears it 
makes. 

When there is very great urgency the cervix may be 
opened by incisions. This is only possible after efface- 
ment. The incisions are generally anterior and posterior 
and extend two or three inches to the vaginal wall. They 
are made with a long handle angular scissors. The other 
instruments needed are two vaginal retractors and two 
tenaculum forceps. All preparations for the subsequent 
operation must be made. 

Symphysiotomy.- — Cutting through the junction of the 
pubic bones is called symphysiotomy. After the bones 
are separated the ends are pulled apart from two to two 
and one-half inches by abducting the thighs. This 
increases the size of the inlet of the pelvis one-third to 
one-half. The operation may be done in a moderately 
contracted pelvis when the course of the labor has shown 
that spontaneous labor is impossible and forceps delivery 
would be dangerous to mother and child. 

The operation is generally followed by the immediate 
delivery of the child either by forceps or turning and ex- 
traction. Hence the preparation for the delivery must be 
made in advance. Repair work must also be provided 
for. Sometimes the bones are reunited by wire sutures. 
Generally they are held in contact with a band of adhesive 
plaster, which must be ready. The patient can be cared 
for better after the operation if she is placed on a sling 



OBSTETRICAL OPERATIONS 



201 



bed that can be raised and lowered with pulleys. This 
also helps to keep the bones in apposition. The cross- 
strip under the patient's buttocks is made so that it can 
be removed for the care of the bowels and urine and 
frequent cleansing of the genitalia. 

In preparing the patient for the operation the pubic 
region must be cleaned as well as possible. The instru- 
ments needed for the symphysiotomy itself are two 
scalpels, one for the soft tissues and one to cut through 
the symphysis, several artery forceps, scissors, small 
retractors, dry dissector, needles, catgut and silkworm 
gut, needle forceps, Sometimes a special symphysiotomy 
knife, Galbiati knife, is used. 



Fig. 79 




Instruments for hebosteotomy, showing Doedlerlein's and Bachelle's 
needles, Gigli wire saw, collodion bottle, and cotton. 



Hebosteotomy. — Instead of cutting between the pubic 
bones the pelvic girdle may be enlarged by cutting through 
one of the bones about a finger's breadth to the side of 
the symphysis. This operation is called hebosteotomy or 



202 



LABOR 



sometimes lateral pubiotomy. The operation is generally 
done subcutaneously. A small incision is made through 
the skin and underlying tissues down to the upper border 
of the pubic bone. Through this opening a special needle 
is carried close behind the bone nearly parallel to the 
symphysis and emerges below the lip of the vulva. A 
wire saw, called a Gigli saw, is then attached to the end 
of the needle and pulled through the track of the needle 
as it is withdrawn. Handles are then attached to the 
ends of the saw and the bone is sawed through. As soon 
as the bone is divided the sawing is stopped in order not 
to injure the soft tissues. The pelvis is then enlarged by 
separating the ends of the bone just as in symphysiotomy. 
After the delivery of the child the ends of the bone are 
brought in contact and held with an adhesive plaster 
bandage. A thread drain may be inserted into one of the 
openings, or both may be sealed up with collodion. 

The instruments needed are the same as for a symphy- 
siotomy with the addition of a hebosteotomy needle and 
a Gigli saw. 

Version. — Version or turning is changing the presenta- 
tion of the child. Cephalic version is changing a breech or a 
cross-presentation to a head. Podalic version is changing 
a head or a cross-presentation to a foot. External version 
is done by external manipulation alone. It may be 
attempted before labor or in the beginning of labor, 
and requires no special preparation. The physician may 
need the assistance of the nurse in the manipulation. 

Combined version is turning with the fingers of one 
hand or the whole hand in the uterus in contact with the 
child and with the other hand on the abdomen. If the 
cervix is opened only so that the fingers can be intro- 
duced the operation may be called combined digital version. 
It is sometimes called Braxton Hicks' version, after the 
name of the English obstetrician who advocated and 
described the technique of the operation. When the 
whole hand can be introduced into the uterus through 
the cervix the operation is a combined manual version. 
This operation is often called simply internal version. 



OBSTETRICAL OPERATIONS 



203 



Combined version is nearly always podalic version, 
and is done to correct a cross-presentation or to bring 
the leg into the cervix to control bleeding in placenta 
previa or to secure rapid delivery, as in prolapse of the 
cord or after symphysiotomy. It should be done on a 
table with the patient anesthetized. No special instru- 
ments are needed unless it be a long dressing forceps or 
perhaps one blade of a scissors for puncturing tough 
membranes. If an arm is prolapsed in a cross-presenta- 
tion a long tape must be ready to slip over the wrist 
before it is replaced to assist in the subsequent delivery. 
If extraction is to follow immediately, preparation must 
be made for the child and for repairs, as will be described 
in discussing extraction in foot and breech presentation. 
If labor is allowed to terminate spontaneously after turn- 
ing the patient and the unborn child must be watched very 
carefully. Generally the physician will remain with the 
patient, but if he should leave the nurse in charge for a 
short time she has a great responsibility not only to 
observe and judge the progress of labor but also to keep 
the patient clean with a limb projecting from the vulva. 

Changing Face to Vertex Presentation. — As labor is 
always more difficult in the face than in the vertex presen- 
tation it is generally desirable to rectify this abnormal pre- 
sentation. If it is discovered early before the membranes 
rupture the physician generally waits until dilatation is 
complete, when he ruptures the membranes and rectifies 
the presentation, or if the membranes rupture spontane- 
ously before the cervix is open he at once changes the 
presentation. If the membranes have been ruptured 
for some time and the waters have drained away the 
uterus will have contracted firmly around the body and 
the head will have passed far along in the pelvis, making 
the operation much more difficult. Here the head must 
first be pushed up out of the pelvis. In all cases it is 
necessary not only to flex the head but also to change the 
attitude of the body from that of the dorsal flexion to 
ventral flexion. Sometimes this operation is done with 
the patient across the bed, but usually the use of 



204 



LABOR 



the table is preferable. The physician introduces one 
hand into the vagina and uses the other for external 
manipulation. The nurse, if she is not giving ether, 
assists by pulling the breech to one side while the 
physician with the external hand pushes the shoulders 
to the opposite side. 

Fig. 80 




Correction of face presentation by manipulation. Arrows show direc- 
tion in which various parts of fetus are carried by operator. A, toward 
the pubes; B, toward the sacrum; C, breech carried toward mother's 
anterior abdominal wall. (Thorn.) 

After the operation, when the patient comes out of the 
anesthetic, it will be necessary to hold the head in the pelvic 
inlet during several pains in order that the contractions 
shall not bring back abnormal presentation. 



OBSTETRICAL OPERATIONS 



205 



Other preparatory operations are occasionally required. 
When the hand or foot presents by the side of the head it 
must be replaced. Anesthesia may be necessary. When 
the head rotates improperly after its descent into the pelvis 
so that the occiput is posterior, the physician may intro- 
duce his hand into the vagina and turn the head around 
so that the occiput comes to the front. The nurse may be 
asked to assist in rotating the body by external manipula- 
tion. Frequently this is done without ether. Sometimes 
in a breech presentation the breech descends into the pelvis 
and then becomes impacted and cannot go farther. Here 
the physician will push back the breech and bring down a 
leg. This requires complete anesthesia. It is followed by ex- 
traction, for which preparation must be made in advance. 

Expression of the Fetus. — Among the delivery operations 
the oldest and simplest is manual expression. From the 
earliest times of which we have record it has been the 
custom of midwives to assist in pressing out the fetus 
often with the crudest and crudest procedures. About 
thirty years ago Kristeller gave the indications for the 
operation and described in detail the method of carrying 
it out so that the operation is often called Kristeller's 
expression. It is indicated only in the second stage of 
labor, and when there is delay and the pressing efforts 
of the mother are weak and insufficient. The physician 
stands at the side of the mother and grasps the uterus 
through the abdomen, with the thumbs in front and the 
fingers behind and at the sides, and presses the child 
downward. A certain degree of anesthesia, which may 
be entrusted to the nurse, is often necessary. Similar 
expression is made in breech extraction. 

Another form of expression is that applied directly to 
the head to force it into the pelvis. This was specially 
recommended by Hofmeier, and is sometimes called by 
his name. It is used when labor is delayed because the 
head cannot enter the moderately contracted pelvis. 
Anesthesia is also required here. 

Watcher Posture. — In the Hofmeier expression as well 
as in other operations where the head has not entered 



206 



LABOR 



the pelvis because the inlet is too small the patient is 
frequently put into the Walcher posture. In this posture, 
as shown in Fig. 81, the lower extremities are extended 
on the hips so as to pull the symphysis away from the 
promontory. When the posterior or sacro-iliac joints 
allow considerable motion the anteroposterior diameter 
of the inlet may be increased nearly an inch. This enlarge- 
ment may make considerable difference in case of a tight- 
fitting head. 

Fig. 81 




Walcher posture. 



In a hospital where there are a number of assistants 
and where a table can be had to lower the shoulders and 
raise the hips it is easy to secure this posture. In a 
private house it is more difficult. If the patient is on an 
ordinary kitchen table with the hips at the edge and legs 
hanging down she must be held by two or three people, 
especially when forceps are applied. Dickinson has pro- 
posed to secure elevation of the hips, and thereby a more 
perfect posture, by using a kitchen chair firmly fastened 
upside down on to the bed or table and covering it with 
blankets and sheets. 

Expressing the Head from the Vagina. — When the head is 
in the vaginal outlet, but held by a firm vulvar ring, it 



OBSTETRICAL OPERATIONS 



207 



may be pushed out by pressing on the posterior wall of 
the birth canal at each side of the anus. This manipula- 
tion may also help to save the perineum from tearing. 
This measure is sometimes called the Ritgen expression, 
although that obstetrician proposed to introduce the 
fingers into the rectum to secure a better hold of the face 
or brow of the child. This, of course, contaminates the 
fingers and is no longer done. This manipulation is done 
only by the physician, and should not be attempted by 
the nurse when she is alone with the patient and obliged 
to conduct the labor. 

Manual Extraction. — In foot or breech presentation, 
although labor may terminate spontaneously, the physi- 
cian is always anxious for the life of the child. As soon 
as the body descends into the pelvis and passes through 
the cervix there is danger that the cord may be compressed 
between the shoulders or head and the sides of the pelvis 
or by the incompletely dilated cervix. This would cut 
off the supply of oxygenated blood from the mother and 
the fetus would suffer, just as a person suffers when he is 
deprived of air. The fetus might begin to make respira- 
tory efforts and thus draw fluid into its lungs and drown 
in the fruit water. 

To prevent this disaster the physician must be ready 
to interfere as soon as the hips begin to pass through 
the vulva. As a rule it is dangerous for the child to be 
more than three minutes passing out of the pelvis after 
the hips are born. Frequently the shoulders and head 
will be detained in the inlet or in the outlet, and traction 
on the portion of the body already born will be required. 
This is called manual extraction. 

All preparation for this interference should be made in 
advance. Some physicians prefer to deliver all breech 
presentations on a table. The nurse must then have the 
table in readiness in the confinement-room or in a neigh- 
boring room and assist in transferring the patient to the 
table before the hips appear in the vulva. Other physicians 
turn the patient across the bed. 



208 



LABOR 



No anesthetic is given, as a rule, because all of the 
powers of the patient are needed to assist in the expulsion. 
If the patient should be very unmanageable it might be 
better to anesthetize her and rely upon traction and 
expression. The nurse must be prepared to conduct the 
anesthesia. 

In combination with traction, pressure on the uterus 
from above may be desirable. Here the nurse may be of 
great assistance. Pressure is applied directly to the 
child's head in the direction of the axis of the inlet. 

In all cases of breech delivery it is necessary to have 
everything ready for resuscitating the child: tracheal 
catheter, hot and cold water, oxygen, etc., as described on 
page 287. 

Sometimes, after turning, extraction is made immedi- 
ately. The method of procedure does not differ materially 
from that just described for breech presentation. 

Some physicians apply the forceps to the after-coming 
head. They will, of course, require the forceps to be in 
readiness. 

Forceps. — In a head presentation, manual extraction 
cannot be employed without turning the child. In olden 
times version and extraction was the method employed 
to remove a child when spontaneous delivery was impos- 
sible. About three hundred years ago the forceps was 
invented for the purpose of ending difficult labors with 
head presentation. It is designed to grasp the head and 
hold it safely while traction is employed to extract it from 
the obstetrical canal. 

The ordinary forceps consists of two crossed pieces 
or branches. Each piece consists of a blade, a handle, 
and a shank. The blade is the broad part, about seven 
inches long, that is applied to the side of the head. It is 
generally fenestrated to make it lighter and hold better. 
It has two curves, a head or cephalic curve to fit the head 
and a pelvic curve to correspond to the curve of the pelvis. 
The handle is thick and corrugated and often has a hook 
so that it may be better grasped in the hand. The shank 



OBSTETRICAL OPERATIONS 



209 



connects the blade and handle and elongates the branch 
so that it may be applied to the head when it is some dis- 
tance above the vulvar outlet. The lock placed at or 
near the junction of the shank and handle is an arrange- 
ment for fastening the branches together. 



Fig. 82 




Obstetric forceps: Milne-Murray axis-traction forceps, a common 
forceps with an English lock, a Naegele forceps with a notch lock, a 
Tarnier axis-traction forceps. 



There are numerous varieties of forceps differing in 
more or less important details. They are generally named 
from the obstetricians who devised the modification. 
Some forceps are made with a short shank and used at the 
outlet. They are called short or outlet forceps. In a well- 
known short forceps the blades are solid. The English 
or Simpson forceps have the English lock, two shoulders 
fitting together. The French forceps have a pivot lock. 
One other kind of lock very frequently employed is the 
notch lock. 
14 



210 



LABOR 



Forceps operations are classified as low, middle, and 
high. Low forceps is the application to the head in the 
lower half of the obstetrical canal. Middle forceps is the 
application to the head in the excavation or cavity of the 
pelvis. High forceps is the application when the head is in 
the inlet or, rarely, above the inlet. 



Fig. 83 




Preparation for forceps operation. 



While the ordinary forceps can be applied to the head 
in the outlet, or in the excavation it will not answer as 
well for high forceps, for with it we cannot make traction 
in the right direction. 

For use in the inlet, Tarnier devised a forceps that is 
sometimes called the inlet forceps, or more frequently 
the axis-traction forceps, because with it traction can be 
made in the line of the axis of the pelvis. The distin- 
guishing feature of this forceps is the presence of traction 
rods and a handle. These rods are attached to the blades 



OBSTETRICAL OPERATIONS 



211 



and pass below them out of the vulva, where they are 
bent backward so that the handle can be fastened low 
down. 

Forceps is indicated in certain cases when there is 
danger to either mother or child. Certain conditions of 
the pelvis and uterus must be present to justify an opera- 
tion. The discussion of this important subject is not 
appropriate in this work. 

The operation would always better be made on a table. 
The physician needs three assistants: one for the ether, 
one to help hold the forceps and assist in expressing the 
child and later to care for the child, and one to bring 
solutions, towels, etc., and wait on him as may be required. 
Frequently, however, in private practice he must be con- 
tent with the nurse and one colleague who generally 
gives the anesthetic. The nurse must prepare beforehand 
everything that may be needed, including solutions, 
sponges, douche, packing, and repair instruments. 

Cesarean Section. — When the pelvis is very small, for 
example, when the anteroposterior diameter of the inlet is 
less than 6 cm. or 2\ inches, the child cannot be delivered 
through the maternal passages and must be removed by 
cesarean section; that is, through an opening made in 
the abdomen and the uterus. Such a contraction of the 
pelvis is said to furnish an absolute indication for cesarean 
section. When the pelvis is larger but still too small 
for spontaneous labor at term we may choose between 
cesarean section and other operations, namely, high 
forceps, symphysiotomy and hebosteotomy, induction 
of premature labor, and embryotomy. This degree of 
contraction, therefore, is said to furnish a relative indica- 
tion for cesarean section. The operation is also made 
sometimes on account of tumors in the pelvis which 
prevent normal delivery and for serious diseases of the 
mother, like eclampsia and placenta previa. 

\Yhen the absolute indication is present the operation 
must be done even if the child is dead and the mother 
already infected. In other cases cesarean section would 



212 



LABOR 



not be done for a dead child and rarely where there is 
infection of the mother. 

If the physician can select the time for the section he 
prefers to operate at the end of pregnancy, that is, a day 
or two before labor is expected. After labor has begun, 
and especially after the membranes have ruptured and 
after the patient has been examined, there is more danger 
of contamination of the patient and consequently more 
risk of infection. 

The operation should be made in a hospital if possible. 
Nowadays no laparotomy is made in a private house if the 
patient can be transferred to a hospital. In cities or large 
towns there are hospitals with fairly well-equipped oper- 
ating-rooms and attendants who understand to assist in 
major operations. In such places a patient requiring 
a cesarean section would always be sent to the hospital. 
The preparation for any laparotomy in a private house is 
still described in text-books on surgical and gynecological 
nursing, and reference must be made to the directions 
there given for the preparation for cesarean section should 
this ever be required in a house. 

The preparation of the patient and the preparation 
for the operation is the same as that for any laparotomy. 
If she is not in labor and there is no urgency she is given 
a laxative and enema the day before the operation. The 
genital region is cleaned as has been described on page 
140. Some obstetricians order a vaginal douche and 
perhaps a thorough scrubbing out of the vagina. If the 
latter is done, sterile cotton sponges soaked in lysol 
solution are used with the gloved fingers after the vaginal 
douche has been given. The swabbing must be done very 
gently so as not to injure the vaginal mucous membrane. 
Ordinarily the vaginal cleaning, including douching, is 
omitted except in cases where labor has begun and the 
membranes ruptured, and especially where numerous 
internal examinations and delivery manipulations have 
been made. An antiseptic dressing is applied to the vulvar 
region, which must be cleaned again before the operation. 



OBSTETRICAL OPERATIONS 



213 



The abdomen is to be shaved and disinfected in the 
manner prescribed for hand sterilization (see p. 132). 
Generally a soap dressing is applied a half-hour before 
shaving. The navel must be cleaned with special care 
and alcohol used freely. A sterile dressing is then applied. 
It is well to repeat the disinfection of the abdomen once 
or twice. When the patient is brought to the table for the 
operation the cleaning is made for the last time. 

Three nurses are needed for the operation: one for the 
instruments and sponges, one for general assistance, and 
one for the baby. If there are enough nurses it may be 
better to have one nurse care for the sponges and another 
for the instruments. Both must be clean and wear gloves. 
The operator also requires two physicians as assistants, 
the first assistant who helps in the operation and the 
anesthetist. 

Five minutes before the incision the patient should 
receive a hypodermic injection of pituitary extract or 
fluidextract of ergot. Another injection should be pre- 
pared for eventual use during the operation. Normal 
salt solution for hypodermoclysis should also be in readi- 
ness for use in case of shock or when much blood is lost. 

For asphyxia of the child there should be a tank of 
oxygen, hot and cold water, and a bath-tub and a proper 
tongue holder, and of course the usual tracheal catheter 
and clamp forceps and ligature for the cord. 

The following instruments are required: two scalpels, 
two scissors, sixteen short and eight long artery forceps, 
four long forceps for sponge holders, four tenaculum 
forceps, four strong curved needles for sewing the 
uterine walls, four tissue forceps, four needles for the 
serous coat, two needles for the fascia in the ab- 
dominal wall, and two skin needles and two needle 
forceps. There should also be strong No. 3 or No. 4 
catgut for the uterine wall. No. 1 or No. 2 catgut for 
the peritoneum and fascia, silkworm gut for the skin, 
or horse-hair for the subcutaneous stitch if that is used. 
For an elastic ligature a thin-walled tube two feet long 
may be provided. 



214 



LABOR 




OBSTETRICAL OPERATIONS 



215 



Laparotomy sheets and towels, pads and sponges, 
dressings, etc., are, of course, provided by the hospital 
or the operator. If the nurse who cares for these is in 
doubt concerning the wishes of the operator regarding the 
preparation or counting of sponges or any other detail 
of the technique she must inform herself in advance. 

Sometimes the uterus is eventrated before it is opened. 
This requires a long abdominal incision. After eventra- 
tion the neck of the uterus does not fill the opening and 
the intestines tend to roll out behind the uterus. This 
is prevented by bringing together the edges of the incision 
with two or three tenaculum forceps. If the uterus is 
opened and the child extracted before eventration its 
body is then drawn outside for suturing and the super- 
fluous opening behind closed with the tenaculum forceps 
as in the first case. The uterus is protected from the 
forceps and line of incision by a large towel or laparotomy 
sheet. 

After the closure of the uterus the nurse must be pre- 
pared for any supplementary operation. The most 
common is the sterilization of the patient by removing 
the tubes. For this the operator requires a scalpel, 
scissors, and suturing outfit. 

When the abdominal wound is closed dressings are 
applied and held in place with adhesive strips and a band- 
age. Subsequent control of the uterus is easier if the 
layer of dressings is not too thick. There will be consider- 
able bloody discharge from the uterus and vaginal cavity 
if the operation has been done before labor begins. 
The vulvar region is to be cleaned and a large vulvar 
dressing applied as after delivery through the obstetrical 
canal. 

The subsequent treatment is that appropriate to a 
laparotomy patient who is also a puerpera. She must be 
looked after carefully for twenty-four hours for vomiting, 
shock, hemorrhage, or pain. Thirst is relieved as soon as 
nausea permits. The bowels generally are moved on the 
third day with calomel, salines, oil, or a hypodermic in- 



210 



LABOR 



jection of a physostigmine salt. The patient is encouraged 
to urinate and catheterization is seldom necessary. The 
vulva is kept very clean and occlusion dressings constantly 
employed. The baby can be put to the breast the third 
day, from which time the course differs but little from 
that in a normal labor. 

Porro-Cesarean Section. — The operation just described 
is called generally conservative cesarean section, because 
the uterus is conserved or saved. If the uterus is already 
infected it is dangerous to try to preserve it, for the 
infection is hard to overcome and is likely to spread. 
Hence when the section of an infected uterus is necessary 
it is generally removed by amputation at the neck. 
Rarely uncontrollable hemorrhage after removal of the 
placenta may necessitate removal of the uterus in a case 
which was started as a conservative section. The amputa- 
tion of the uterus in connection with a section is called 
the Porro operation, after the name of the Italian obstet- 
rician who first performed it. There will be needed a 
large number of artery or clamp forceps and a number of 
strong catgut ligatures. Otherwise the nurse's prepara- 
tion will be the same as for the conservative section. 

Occasionally after the removal of the child the uterus 
is not amputated, but the entire organ is removed for 
infection or where there is cancer of the cervix. As the 
vagina must be opened it should be thoroughly disinfected 
beforehand. 

Extraperitoneal Cesarean Section. — Within the last five 
years another operation, called extraperitoneal cesarean 
section, has been devised especially for unclean cases 
where section is indicated. The abdomen is opened low 
down, generally with a Pf annenstiel or transverse incision ; 
the bladder is pushed to one side and the peritoneum 
pushed up so that space is obtained to open the cervix 
and lower part of the uterus below and outside of the 
peritoneum. In this way the possibly contaminated 
fruit water is prevented from entering the abdominal 
cavity. After the emptying of the uterus it is sewed up 



OBSTETRICAL OPERATIONS 



217 



and likewise the abdominal wound. As the uterus is 
preserved the operation is a modification of the conserva- 
tive cesarean section. 

The preparation for the operation differs little from 
other sections. The patient is generally placed in the 
Trendelenburg Posture, that is, with the hips elevated. 
A few ounces of normal salt solution are injected into the 
bladder just before the operation begins to aid in its 
manipulation. Retractors are necessary to hold the edges 
of the wound apart and to displace the bladder while 
preparing the uterus for incision. 

Postmortem Cesarean Section. — If the mother dies 
suddenly from any cause either during labor or in the 
last months of pregnancy the child may remain alive in 
the uterus for twenty minutes and can be saved if quickly 
removed by an abdominal section. This is called post- 
mortem cesarean section. No instruments are needed 
except a scalpel and no previous preparation is required. 
Afterward the incision is closed by sutures. 

Vaginal Cesarean Section. — When the pelvis is large 
but the uterus closed delivery may be effected by opening 
the uterus from below. This vaginal cesarean section 
may be indicated when the cervix cannot be dilated as in 
cancer of the cervix or when rapid delivery may be neces- 
sary on account of eclampsia or other maternal disease. 
It was stated on page 200 that in urgent cases the cervix 
could be opened with incisions provided it was effaced. 
Before effacement the incisions in the cervix are not 
sufficient. It is here necessary to carry the incision up 
some distance into the body. The bladder is separated 
from the anterior vaginal and uterine walls, and the latter 
is then incised as far as the peritoneal covering. This is 
then pushed up and the incision extended as far as may 
be necessary. In vaginal cesarean section the peritoneal 
cavity is not opened. The child is removed either with 
forceps or with turning and extraction. The closure of 
the wounds in the uterus, cervix, and vagina is made with 
catgut. Some begin repair in the uterus before removing 



218 



LABOR 



the placenta, while others remove the placenta at once 
after extracting the child and pack the uterus to prevent 
hemorrhage. 



OBSTETRICAL OPERATIONS 



219 



The operation is made like most vaginal operations 
with the patient in the lithotomy position at the end of 
the table. It is very important to have a good light that 
can be thrown into the vagina. Three nurses are neces- 
sary: one for the instruments, one for general assistance, 
and one for the baby. The operator also needs three 
physicians as assistants, one anesthetist, and one on each 
side to hold retractors and otherwise assist in the operation. 

The preparation of the patient is the same as for an 
abdominal section. The abdomen should be cleaned, 
because the turning of the child will make it necessary 
to manipulate through the abdominal wall. The vagina 
must be well disinfected (page 212). The bladder and 
rectum must be empty. To protect the vagina from 
contamination from the anus a small towel may be fastened 
to the perineum and the buttocks by short tenaculum 
forceps or by sutures. 

The following instruments are needed : two large vaginal 
retractors, two large narrow retractors, for holding the 
bladder away from the cervix, four Doyen forceps, four 
tenaculum forceps, two sponge forceps, four long artery 
forceps, one long-handled scissors, four curved needles, 
two needle holders, twenty-day No. 2 catgut, obstetrical 
forceps, and also gauze for packing the uterus. 

Embryotomy. — Embryotomy means literally cutting up 
or cutting into the embryo. It is done for the purpose 
of making the fetus smaller so that it will pass through 
a contracted obstetrical canal. Sometimes both the head 
and the body are cut up. Much more frequently the head 
alone is cut open. This is called craniotomy. The per- 
foration of the skull may be done with a pointed scissors- 
like instrument whose branches are sharp on the outside 
and cut when opened. A sharp-pointed instrument that 
is pushed or screwed into the skull may also be used. 
After the perforation a long tube or forceps is introduced 
into the skull cavity to break up the brain, which is 
pressed out of the opening as the head is compressed. 
After the perforation and consequent decrease in size 



220 



LABOR 



of the head the delivery may be left to nature. More 
frequently an instrument which grasps and compresses 
the head is used to extract it. Such an instrument is the 
Braun cranioclast. One blade is introduced into the 
cranial cavity to the base of the skull and the other one 
on the outside of the skull or face. They are then brought 
forcibly together by a screw. A cephalotribe is a modified 
obstetrical forceps with strong blades to seize the head 



Fig. 86 




Embryotomy instruments: Braun hook; Auvard's cranioclast; cleidot- 
omy scissors; Braun's cranioclast; Smellie's perforator. 



and crush it. The instrument most used nowadays was 
devised by the French obstetrician Auvard, and is a 
combination of these two instruments. It has three 
blades, the middle one of which is introduced into the 
skull cavity, a second, with which the inner blade forms 
a bone forceps like the cranioclast, and a third, which 
is applied to the opposite side of the head and forms with 
the second a cephalotribe. Generally the middle blade 



OBSTETRICAL OPERATIONS 221 



is sharpened to serve as a perforator. The operation of 
grasping the head with the cranioclast, which involves 
more or less compression or breaking up, is called cranio- 
clasis. The operation with the cephalotribe is cephalo- 
tripsy. A basiotribe is a modified cranioclast or cephalo- 
tribe designed especially for crushing the base of the skull. 

Craniotomy is indicated when there is a contracted 
pelvis and a dead child. The pelvis must not be too 
small else the child cannot be extracted even if the head is 
made smaller. We regard an anteroposterior diameter 
of the inlet of the pelvis of 6 cm. as the boundary line 
separating the indications for craniotomy and the absolute 
indication for Cesarean section (see p. 211). Formerly 
craniotomy was done even on a living child, but this 
operation is now almost entirely abandoned. 

Rarely the craniotomy is done without an anesthetic if 
the vagina is not sensitive. Usually, however, the extrac- 
tion follows the perforation, and anesthesia is desirable. 
The patient is in the lithotomy position on the end of a 
table prepared as for a forceps operation. The instru- 
ments required are the same as for forceps, with the 
exception of the perforator and cranioclast. 

Decapitation. — Version is a dangerous operation in a 
neglected cross-presentation after the liquor amnii has 
drained away and the uterus firmly contracted around 
the child and fitted to it. It is apt to cause that most 
serious accident, rupture of the uterus. If the child is 
dead, decapitation is much safer for the mother. This 
is done with a Braun hook. Anesthesia is required and 
the same preparation as for forceps. 

Removal of the Placenta. — The expression of the placenta 
has been described on page 178. The manual removal 
there alluded to is done only by the physician. No instru- 
ments are required, but the patient must be thoroughly 
anesthetized. The operation is generally done with the 
patient across the bed, but sometimes she is put on a 
table. An intra-uterine douche must be in readiness as 
well as the outfit for packing the uterus. 



222 



LABOR 



Repair Operations. — Tears of the cervix and the upper 
part of the vagina can be repaired satisfactorily only 




OBSTETRICAL OPERATIONS 



223 



with the patient on a table and in a good light. Like- 
wise extensive and deep tears of the perineum extending 
up into the vagina or back into the rectum can be mended 
much better with the patient on a table. Slight super- 
ficial lacerations can be repaired with the patient in bed, 
her hips raised on a douche-pan, and frequently while 
waiting for the birth of the placenta (see p. 194). 

The repair instruments which should be in readiness 
after the labor in all primiparse and whenever required in 
multipara? are the following: two, sometimes four, vaginal 
retractors, four short and two long tenaculum forceps, two 
long and two short artery forceps, one dressing forceps, 
four medium curved needles for the vagina, four larger 
needles for the perineum, one needle forceps, No. 2 catgut 
twenty-eight inches long, and several strands of silkworm 
gut. 

For good work the physician needs four assistants: 
the anesthetist, a clean assistant to help with the retractors 
and sponges, and another clean assistant to care for instru- 
ments and sutures, and a general assistant to care for 
supplies, light, etc. Generally, however, the physician 
must be satisfied with an anesthetist and one nurse. 
The patient's legs are held with the sheet leg holder, 
and the nurse stands at her right side and assists with 
the retractors. The instruments, sponges, etc., have 
been prepared beforehand and are placed on a table of 
sufficient size on the right of the operator. The nurse 
wears gloves while assisting with the instruments and 
removes them if she has to leave her post. 

Instead of attempting a difficult repair with too few 
assistants and with insufficient preparation many obstet- 
ricians defer the operation for a few hours or even for a 
day or two until satisfactory assistants can be secured. 
Some even refuse to make any immediate repairs and wait 
for several days, when the patients are carefully examined 
and all injuries attended to. This course often reveals 
obscure injuries that would be overlooked immediately 
after labor. 



224 



LABOR 



Vaginal Douche. — The technique of the hot vaginal 
douche for postpartum hemorrhage has been described 
(see p. 181). The cleansing antiseptic, vaginal douche, 
intrapartum and postpartum, should begin with the 
patient on her back on a douche-pan or on a drainage 
sheet. Whether water alone or normal salt solution or 
some antiseptic solution be used the water should be 
sterile. A fountain syringe of rubber or enamel ware 
should always be provided, and this should be sterile as 
well as the tubing and glass douche-point. The receptacle 
should not be too high and give too great pressure. The 
quantity of water required depends upon the object of the 
douche, but generally three quarts is sufficient. The vulva 
must first be well cleaned and then the labia separated 
before introducing the tube. The nurse must remember 
that the direction of the vagina is backward and inward. 

Intra-uterine Douche. — This is given only by the physi- 
cian. If he employs it for postpartum hemorrhage he 
may use the usual vaginal douche-point because the cervix 
is still well dilated and there is no obstruction to the 
return of the fluid from the uterus. During the puerperium 
the douche may be employed in puerperal fever. As the 
cervix is now more or less closed he must provide for a 
return flow by using an intra-uterine douche-point, else 
the fluid might be forced out of the cavity of the uterus 
into or through the tubes. For the same reason he will 
not have the reservoir too high above the uterus. The 
patient must be on a table or possibly across the bed. 
He may get along without any instruments, but generally 
the nurse should prepare two vaginal retractors, one 
tenaculum forceps for catching the portio, dressing forceps 
and sponges, and a solution for cleaning the vagina and 
cervix. 

Intra-uterine Tamponade. — The technique of the vaginal 
tamponade to prevent hemorrhage in placenta previa 
or abortion has been given (see p. 94). The intra- 
uterine tamponade to control postpartum hemorrhage is 
used more freely by some physicians than by others. It 



OBSTETRICAL OPERATIONS 



225 



is generally applied with the patient on her back across the 
bed or, better, on a table. As the operation is quite painful 
some physicians prefer to give an anesthetic. This reduces 
the shock of the operation, but also delays it. When the 
hemorrhage is severe and cannot be controlled with 
massage it may be necessary to pack immediately without 
ether in spite of the pain caused by the operation. 

The instruments needed are two vaginal retractors 
or a large Neugebauer speculum, two tenaculum forceps 
for holding the cervix, a dressing forceps, and a scissors. 
A strip of sterile gauze, nine to eighteen inches wide and 
eight to thirteen yards long, is needed for the packing. 
The physician may have prepared this beforehand and 
brought it with him in a sealed tube or jar. If not the 
nurse must cut off a strip of proper width from the twenty- 
five-yard roll of gauze of the patient's outfit. 

For the packing the obstetrician should have two 
nurses besides the anesthetist. One is at the side of the 
patient and holds the retractors or assists in holding 
the uterus while the other holds the jar of gauze and if 
necessary one of the retractors. A packing tube enables 
the operator to dispense with one nurse and at the same 
time introduces the gauze without the danger of 
contamination. 

Hypodermoclysis. — The injection of a quantity of 
liquid under the skin is hypodermoclysis. The technique 
of the injection for hemorrhage has been described on 
page 186. It is also used to overcome shock. Generally, 
normal salt solution which is absorbed about as easily 
as blood-serum is the liquid chosen. To recapitulate here 
the rules for its administration it may be said : the needles 
must be large enough, the apparatus and solution must 
be sterile, the solution must be kept warm, it must never 
be injected into the breast but some distance below the 
breast or into the front of the thighs, and not more than 
8 to 10 ounces should be injected into one place. 



1.3 



CHAPTER V. 



CHILDBED, LYING-IN PERIOD, PUERPER1UM. 

These terms are equivalent and are generally used 
to denote the period from the end of labor, that is, the 
birth of the placenta to the completion of the change in 
the genital organs when they resume a condition normal 
for a woman who has borne children. 

Duration. — There is some difficulty in defining the 
duration of childbed. If the term were used literally 
to denote the length of time that the patient remained in 
bed we should find that its duration varied greatly accord- 
ing to the social condition of the patient, the custom of 
the time and place, the ideas of the attending physician, 
etc. In some cases it would last four or five weeks, more 
frequently nine to twelve days, often only two or three 
days, while in the case of the North American Indian 
female there is, literally speaking, no childbed, for it is 
not her custom any more than that of animals to lie down 
after labor. If we should take the presence of the discharge 
or lochia as the measure of the duration of childbed we 
should also have some confusion. Although frequently the 
discharge ceases in about two weeks, still it frequently 
continues longer and often returns after the patient gets 
out of bed. Moreover it may run into a more or less 
permanent leucorrhea. It is therefore best to make the 
limit of the puerperium coincide with the resumption 
of the normal condition of the genital organs. After labor 
the uterus, its appendages, and the abdominal wall all 
begin to decrease in size. This process is called involution. 
It comes on with varying degrees of rapidity, but in ordi- 
nary normal cases it is completed in from six to twelve 



LOCHIA 



227 



weeks; hence this may be considered the duration of the 
lying-in period. As a rule it is only during the first third 
or half of this period that the patient is under the care of 
the nurse and physician. Yet the resumption by the 
patient of all of her household or social duties before the 
completion of this period may lead to incomplete involu- 
tion with unpleasant and lasting complications. 

Lochia. — The discharge from the genitals during child- 
bed is called the lochia. For a day or two it is frequently 
composed mostly of blood, although it would not be 
proper to include under this term a severe bleeding or 
hemorrhage after labor. It comes chiefly from the uterus 
and may be considered a wound discharge. Besides the 
bleeding from the opened and injured vessels it is also 
due to changes in the placental region and in the decidua, 
the transformed mucous membrane of the uterus. The 
discharge gradually becomes lighter in color, containing 
less and less blood until after seven to fourteen days it 
may be only a slimy or partly purulent discharge, which 
continues for a few days longer and then ceases. It may 
disappear for a few days to reappear when the patient 
sits up or moves around much or because of a displace- 
ment of the uterus or from some unknown cause. It 
may be difficult to distinguish such a reappearance of the 
lochial discharge from menstruation. The quantity and 
duration of the lochia varies greatly in different women and 
also depends upon the character of the labor and other 
causes. It frequently has a peculiar and somewhat disa- 
greeable odor due to decomposition caused by bacteria. If 
all bacteria in the vagina and on the vulva were destroyed 
during labor and kept away from the genital outlet after- 
ward all odor would be prevented. This peculiar smelling 
lochia is not very dangerous, but as a sign of contamina- 
tion it should be prevented as much as possible by care in 
the genital dressings. A more offensive lochia due to the 
colon bacteria and sometimes to other germs may indicate 
a more dangerous contamination. The presence and char- 
acter of any odor as well as the color, nature, and quantity 



228 



PUERPERIUM 



of the lochia, should always be carefully entered on the 
history sheet. The stoppage of the lochia indicates lack 
of drainage from the uterus and is not uncommon in 
cases of infection of the uterus; hence it should be watched 
for and reported. 

Care of Bed, Cleaning of Patient, and Care of Genitals.— 
As was said in the preceding chapter the contraction of the 
uterus should be carefully observed for several hours by 
examining frequently with the hand through the abdomi- 
nal wall, and if it is found to contract poorly, sometimes 
becoming large and soft, while at the same time consider- 
able blood escapes from the vagina, it should be stimu- 
lated to continued contraction by rubbing through the 
wall of the abdomen and by other measures before referred 
to. In cases of postpartum hemorrhage the change of the 
bed and dressing of the patient is deferred until the bleed- 
ing is stopped. When the vagina or perineum is torn 
the application of the dressing is also delayed until the 
lacerations are repaired. In normal cases, however, 
as soon as the after-birth is expelled the patient may be 
cleaned and the bed changed. If the draw sheet or pad 
under the patient is much soiled it is rolled together and 
removed and a clean sheet underlaid. Then all blood- 
spots are washed off from her body, if necessary her 
nightdress is changed, and then the douche- or bed-pan 
is put under her and the genitals thoroughly cleaned 
from clots with soap and sterile water and later bathed 
with sublimate or lysol solution. A large, thick napkin 
is then applied, the sheet with the rubber draw sheet 
removed and a clean draw sheet put under her, when 
the change from the labor-bed to the bed of the lying-in 
period is complete. 

The abdominal bandage may now be applied and the 
napkin fastened. Some physicians object to this bandage. 
If it is so applied that it can roll up and make a kind of 
cord around the middle of the body it becomes uncomfort- 
able and useless. If it remains on too long and becomes 
soiled with the discharge it becomes dangerous. But if 



CARE OF PUERPERA 



229 



properly applied it relieves the patient from the unpleasant 
feeling caused by the change in the pressure within the 
abdomen, prevents the tendency to displacement of the 
abdominal organs, especially if they have been previously 
prolapsed, and perhaps aids the patient in regaining a 
good shape. The bandage should be changed at least 
every day and as often as it becomes at all soiled. It should 



Fig. 88 




Abdominal and breast bandage and vulvar dressing. 



be made of strong cotton cloth, long enough to reach 
around the body and lap sufficiently to pin, and wide 
enough to reach from below the trochanters or upper 
projecting parts of the thighs to within an inch of the lower 
end of the sternum, that is, about twelve inches. The 
four yards of cotton cloth furnished in the obstetrical 
outfit is sufficient for eight bandages, part of which may 
be used for breast bandages if desired. The abdominal 



230 



PUERPERI UM 



bandage should be fastened in front with a sufficiently 
large number of safety pins to hold it smooth and well in 
place. The lower edge is drawn so tightly that it will not 
slip up over the trochanters. 

To this bandage, made as described in the previous 
chapter, the vulvar dressing is fastened at each end so 
that it makes a fairly good occlusion bandage. The 
essential point is to make the ends of the dressing wide 
and fasten them firmly at the corners so that they fit 
well in the groin in front and against the sides of the 
back behind. In this way the discharge cannot run 
out between the thighs and abdomen along the groin 
as soon as the patient turns on her side, as generally 
happens if the dressing is fastened only in the middle or 
held in place with the ordinary T-bandage. 

The T-bandage is unsatisfactory not only because it 
does not hold the napkin well in place, but also because 
the piece which goes between the thighs is soon soiled and 
cannot be discarded without the whole bandage. 

The frequency with which the napkin should be changed 
depends upon the amount of discharge. The rule is to 
never let the napkin become saturated. When this occurs 
it forms a good soil for bacteria, which quickly penetrate 
to the vulva. As a rule the napkin must be changed 
every half to two hours for three or four times after 
labor, then for two days every three hours, and afterward 
every four to six hours, or as often as the patient passes 
urine or feces. Whenever a fresh napkin is applied the 
clean douche-pan should be put under the patient and the 
nurse with clean hands should wash off all traces of dis- 
charge from the whole genital region from the pubes to 
the anus, using plenty of warm water and soap. For 
washing she may have a basin of water and cotton or 
gauze sponges placed close to the douche-pan. Instead 
of sponging the parts for simple washing the vulvar or 
external douche may be employed. The water or solution 
in a pitcher is poured over the genital region until all 
discharge is washed away and then the labia are separated 



CARE OF PUERPERA 



231 



by the thumb and finger of the left hand and the vestibule 
thoroughly washed with the remainder of the liquid. 
Instead of the pitcher the irrigator may be used. If the 
patient has had a bowel movement she should be sponged. 
It is important that the anal region should be thoroughly 
washed first, and care should always be taken not to rub 
upward, that is from the anus toward the vulva. Of 
course the sponge that comes in contact with the anal 
region should not be used in washing around the vulva. 
After the cleansing with soap and water the genital region 
is washed with a disinfectant solution, sublimate 1 to 2000, 
carbolic acid 1 to 2 per cent., lysol 1 per cent., according 
to the direction of the attending physician. Then the 
fresh napkin is applied. 

Not only must the napkin be changed as often as it 
becomes soiled, but the bedclothes as well. The draw 
sheet or pad which can be easily changed should protect 
the lower sheet. The bed covering should be light and 
comfortable. The comfort of the patient depends much 
upon the care of the bed, which must be well made 
morning and night and constantly kept smooth and clean. 

Cared for in this way the chances are that the lochia 
will be free from odor, any repaired laceration will heal 
without any trouble, and no trace of fever be present. 

Formerly the vaginal douche was considered necessary 
in all cases to remove germs that might remain in the 
vagina after labor or to remove the lochia which was 
thought to be poisonous. Now it is pretty generally 
abandoned because of the danger that attends its routine 
use when by any lack of care healing wounds may be 
broken open and germs carried into the vagina from the 
outside. Moreover it has been found to interfere with the 
power of cleansing itself which the vagina possesses. 
Hence it should never be given by a nurse unless it is 
ordered by the physician. It may be required when there 
is offensive lochia, for hemorrhage, or in cases of delayed 
involution of the uterus. For offensive lochia a cleansing 
douche generally of sterile water or a mild disinfectant 



232 



PUERPERIUM 



solution at a temperature of about 100° is given two to 
four times a day. For postpartum hemorrhage, as has 
been previously said, a hot douche is required. In the 
third or fourth week of childbed a large, flabby uterus 
may be stimulated to contract and undergo the involution 
changes by a douche as hot as can be borne. 

An intra-uterine injection is sometimes used in cases 
of postpartum hemorrhage, and also occasionally in cases 
of infection of the uterus. It is a rather serious procedure 
and should always be given by the physician. Should 
he ever entrust this to a nurse he would give her special 
directions in the method of its performance. 

Puerperal Fever or Genital Wound Infection. — In all 
cases of labor in primiparse and frequently in multiparas 
some abrasions, if not tears, of greater or less extent, 
occur about the vulva and in the vagina and cervix. 
Moreover the inside of the womb is practically a large 
raw or wound surface. These wounds, like wounds in 
other parts of the body, become infected when infectious 
matter, that is matter containing bacteria, comes in 
contact with them. Before labor the germs may possibly 
have been present in the vagina or more commonly on 
the skin about the vulva and rectum. They may have 
been brought to the wound by the hands of the patient, 
nurse, or physician before, during, or after labor. The 
wound may likewise have been infected by soiled napkins, 
clothes, or bedclothes. The bed of the patient may have 
been contaminated by a dirty bed-pan or by the soiled 
clothes of physician, nurse, or relatives of patient if they 
have sat on the bed. Impure water used to wash the 
wound may likewise be the source of infection; likewise 
a contaminated douche. These sources of infection 
have been referred to when describing the preparation 
for labor. The air, which is so frequently accused as 
a source of infection, is probably very rarely the cause 
of trouble, and the elaborate precautions sometimes 
advised, such as stopping up the pipes of stationary 
washbowls, etc., are quite needless and superfluous. 



PUERPERAL FEVER 



233 



The severity of the infection depends upon the amount 
or extent of the infection, the nature of the infection, 
that is, the kind of infecting bacteria, and the resistance 
of the patient to the invasion of the germs. The most 
common infecting germs are the streptococci, or chain 
bacteria, similar to those which cause erysipelas; staphy- 
lococci, or bacteria which grow in clusters like those which 
commonly cause boils; gonococci, or those which cause 
gonorrhea; colon bacteria, that is, those which live in the 
colon, which cause disease when growing in wounds; the 
Klebs-Loffler bacilli, which cause diphtheria; and various 
germs which cause decomposition of dead matter. When 
only a few germs obtain access to a wound, or when the 
germs are not very virulent, or when the resistance of the 
tissues of the body is great, the germs may grow only a 
short time before they are killed and thrown off from the 
body. When the germs are present in great numbers, 
or more virulent in character, or the tissues less resistant, 
the infection may spread superficially or penetrate deeply, 
causing severe local and general disturbance. The method 
of extension of the infection differs according to the char- 
acter of the bacteria; for example, streptococci penetrate 
deeply into the tissues/ while gonococci spread over the 
surface, perhaps from the vulva into the vagina, through 
the uterus, into the tubes. The germs thus cause both 
local and general disturbance. 

Symptoms. — The local symptoms are heat, swelling, 
and tenderness of the region infected, together with more 
or less discharge which may or may not have an offensive 
odor. If the infection is quite circumscribed there may 
be so little trouble that the patient may remain quite 
unconscious of it. Sometimes the discharge is the chief 
symptom, but it may be confounded with the lochia 
and so pass unnoticed. Hence it is important that the 
nurse examine carefully and record on the history sheet 
the character of the lochia. There may be present one 
or more inflamed patches in the vulva or vagina which 
frequently become covered with a pseudo- or false diph- 



234 



PUERPERJ UM 



theritic membrane, and hence are called diphtheritic 
or puerperal ulcers. If the infection penetrates into the 
tissues surrounding the uterus it may cause a large amount 
of serous or purulent matter to be poured out, causing 
tenderness and resulting in abscess or lasting pelvic 
disease. If the infection penetrates through the uterus 
and surrounding tissues to the peritoneum, or if it spread 
through the tubes to this membrane, it causes either a 
local peritonitis limited to the membranes affected, 
shown by local pain, or perhaps a general peritonitis 
shown by a general distention of the abdomen and much 
pain, with all the other serious symptoms accompanying 
this condition. Sometimes the infection spreads through 
lymphatics or veins to other parts, setting up local 
lymphangitis or phlebitis. If carried to the thigh and 
leg and deposited in the large lymphatics and veins of 
the inside of the upper part of the thigh it causes a swelling 
or edema of the limb which is in consequence very pale 
and is called "white leg" or "swelled leg." This condi- 
tion has also been called "milk leg," because from its 
milky appearance it was supposed to be due to the milk 
that left the breast. In this condition the milk frequently 
dries up because of the fever and general infection. The 
Latin name for this condition is phlegmasia alba dolens. 

Besides the conditions just enumerated, sometimes when 
the infection remains more or less local the bacteria 
penetrate quickly through the lymph and bloodvessels 
and are then carried in the circulating fluids all over 
the body. This condition may be called bacteriemia, 
that is, bacteria in the blood; or septicemia, that is, septic 
matter in the blood. The circulating bacteria may lodge 
anywhere in the vessels or in any organs and grow and 
form abscesses. In this way we may have pus in the blood 
or pyemia and abscesses in any organs, as in the kidney, 
liver, skin, etc. 

Besides, the disturbance caused by the bacteria them- 
selves, either when they remain confined to certain locali- 
ties or when disseminated throughout the body, there are 



PUERPERAL FEVER 



235 



other symptoms caused by the distribution through the 
body of poisons generated by the growing bacteria. We 
may suppose that as bacteria grow they produce a very 
deadly poison which readily passes into the bloodvessels, 
is carried to the brain as well as to all other tissues of the 
body. The amount of these poisons depends upon the 
extent of the infection, that is, the number of bacteria. 
In bacteriemia, for example, the amount of poison pro- 
duced might be very great. Their effects depend largely 
upon the kind of infection. For example, the poisons 
produced by the gonococci are much less serious than 
those produced by the streptococci. The circulation of 
these poisons gives rise to what we call the general symp- 
toms of an infection, viz., chill, fever, rapid pulse, vomit- 
ing, loss of appetite, sometimes diarrhea, delirium, etc. It 
will be necessary to study these symptoms somewhat in 
detail. 

A chill may be of all degrees of severity, from a slight 
feeling of coldness to a severe shivering or shaking of the 
whole body. The temperature may be normal or sub- 
normal at the time of the chill, but generally rises shortly 
afterward, or it may be high at the time. As a sign of 
infection it is important and should lead the nurse to 
take the temperature frequently after it. 

It is, however, important to know that a chill imme- 
diately following labor is a not infrequent occurrence, 
generally does not indicate any infection, and ordinarily 
need not occasion any anxiety. It is controlled by cover- 
ing the patient warmly and giving her a hot drink. 

Fever is one of the most important symptoms of an 
infection and is generally taken as an index of its severity, 
and, as we know, gives the name to the diseased condition, 
viz., puerperal fever. It is first necessary to define what 
is meant by fever. For practical purposes we have to 
draw an arbitrary line. We say that a temperature over 
100° is fever. In this way we allow for slight variations 
in the temperature of the body due to local rises in tem- 
perature, for example, such as result from the severe 



236 



PUERPERIUM 



muscular exertion of labor. We assume what is almost 
always true, that a temperature of over 100° means an 
infection. Rise in temperature is often ascribed to worry 
or fright, but generally without reason. Also the common 
idea that the establishment of the milk secretion is attended 
with fever is contrary to the results of investigation. 
Hence we may confidently assume that fever after labor 
is due to some infection, either in the genital tract or the 
breasts, or in some organ not connected with the child- 
bearing process, like the throat, lungs, etc. 

Since increased temperature is an important symptom 
it is of greatest consequence that the physician may be 
able to rely absolutely upon the record made by the nurse. 
Therefore it is her duty to know that her thermometer 
is correct, that it is properly held by the patient, that the 
temperature is taken as often as necessary, and that it is 
correctly recorded. 

There are numerous variations in child-bed fever corre- 
sponding to the differences in the infectious process, 
and temporary fever lasting from a few hours to two or 
three days is due to a limited infection which generally 
leaves behind little or no traces. The height of the fever 
determines the amount of intoxication by the bacterial 
poisons. If the fever is associated with an offensive 
discharge it denotes the presence of germs of decomposi- 
tion and the condition is not as dangerous as in the case 
of a similar fever where the lochia has no odor. A long- 
continued fever without peritonitis often denotes the 
presence of the infectious process around the uterus. All 
of the meanings of fever are learned only by much study. 

Next in importance to the study of the body tempera- 
ture is that of the pulse. Immediately after labor the 
pulse is often uncommonly slow. A pulse rate of 55 to 60 
is not uncommon and sometimes as low as 45 to 50. The 
slow pulse rate may continue two or three days. The cause 
of this singular phenomenon is not certainly determined. 
Like the chill initiating the puerperium it has no patho- 
logical importance. 



PUERPERAL FEVER 



237 



Immediately after labor a rapid, weak pulse leads to 
the suspicion of hemorrhage, which should be carefully 
watched for. Later in childbed, fever is associated 
with a rapid pulse. The two symptoms, however, do 
not always go hand in hand. In the worst cases of puer- 
peral sepsis the fever may be low, while the fast, soft 
pulse warns us of the seriousness of the danger. 

The other general symptoms already mentioned, head- 
ache, loss of appetite, vomiting, etc., need not be further 
considered, for they do not differ essentially from the 
same symptoms in other diseases of infectious nature. 

Treatment. — In the treatment of puerperal fever, while 
the physician is responsible for the general management, 
the nursing is very important. Some physicians lay more 
weight upon the local treatment and some believe in a 
general symptomatic treatment, that is, they support 
the patient while nature cures. 

Direct local treatment of a case, so far as the nurse 
is concerned, means generally vaginal douches. These 
are used especially when there is any odor to the discharge 
and when there are vaginal ulcers. The manner of giving 
such douches has been described already. In caring for a 
patient it is well for the nurse to keep constantly in mind 
the poisonous nature of the discharge and avoid as far as 
possible contaminating with it her hands or clothing. 
When the hands become soiled they should be at once 
disinfected before the contamination has lasted long and 
before the hands have come in contact with other parts of 
the body and the clothing. Here is a place where the nurse 
should wear gloves, not to protect the patient but to pro- 
tect herself. It would be well also for her to protect her 
clothing when she is caring for the patient by wearing a 
large apron. The vulvar dressings should be burned and 
the patient's garments and bedlinen should be kept, 
until boiled, in a large bag separate from other wash. 
The excretions should be disposed of at once, the bed- 
pan boiled or sterilized with a strong antiseptic solution 
(1 to 500 sublimate solution). 



238 



PUERPERIUM 



If a nurse is in a hospital and has care of a fever case 
while she is obliged to attend clean patients she must 
carry out these rules with the utmost thoroughness to 
prevent contamination. Not only must she have for the 
fever patient gloves and apron which are left in the 
patient's room, but also she should wear gloves while 
waiting on other patients. Fever patients should be 
separated from clean cases, and should be cared for by 
nurses that have nothing else to do if possible. 

In the general or symptomatic treatment the most 
important indication is to relieve pain. For the relief 
of local pain in peritonitis, in milk leg, etc., the warm, 
moist dressing is very valuable. This dressing consists 
of a wet cloth like a folded towel wrung out of warm 
water, covered with an impermeable material like oil 
silk or rubber cloth, and kept warm by placing over the 
whole a hot-water bag filled about one-quarter full with 
hot water. A swelled leg should be lifted on pillows or 
blankets and bandaged with cotton, with the moist dress- 
ings applied over the groin and inside of the thigh. An 
icebag or ice-water coil has much the same soothing 
effect and is frequently to be preferred. 

The distention of the bowels with gas, or tympany, is 
a cause of much pain and disturbance to the heart and 
respiration. It can be relieved sometimes by medicine 
and frequently better by large enemata as described on 
page 75. 

High temperature in cases of puerperal fever is best 
controlled with a sponge-bath and with an ice-bag to the 
head. The various excretions of the body should be kept 
free. The kidney excretion is favored by the use of large 
quantities of liquid given by the mouth and by salt 
solution enemata. The bowel excretions are favored 
by the use of salines and enemata. The skin is kept in 
good condition by free bathing. 

The strength is kept up by attention to the feeding 
and by the careful conservation of all the body energy. 
The diet must consist of water, plain or carbonated; milk; 



PUERPERAL FEVER 



239 



easily digested food given with regularity at proper inter- 
vals. Often the patient is not hungry and would go for 
days without asking for food. Careful observation must 
determine what quantity of food the patient can take and 
digest and what is the proper interval for feeding. In the 
preservation of the strength of the patient we must not 
only avoid all loss of energy by any unnecessary exertion, 
but also the loss of heat which follows exposure. 

If the fever is high or lasts more than a day or two, 
nursing must be suspended. Generally the secretion of 
milk will be lessened and its quality impaired so that it 
will not be suitable for the baby. Moreover, the strength 
of the mother, which must be conserved, is affected by 
nursing. She may be told that she will not lose her 
milk or that it will return as soon as the fever leaves. 

Puerperal Tetanus. — A special form of puerperal 
infection is puerperal lockjaw or tetanus. Like all forms 
of tetanus it is due to a special kind of bacterium that is 
often found on the ground or floor. The germ is especially 
found around horses and some other domestic animals. 
Cases of puerperal tetanus have been ascribed to the intro- 
duction of unclean ice or snow into the uterus to stop 
hemorrhage. It might be produced by the use of dirty 
cloths for napkins, or by a dirty douche-point. The 
treatment is that of tetanus from any other source and 
cannot be given here. 

Puerperal Insanity. — Another rare puerperal disturb- 
ance may be mentioned here, namely, puerperal insanity. 
It is occasionally the result of infection, but according 
to our present knowledge is also due to a variety of other 
causes, the chief of which is exhaustion following a severe 
labor in a weakened anemic person. The insanity gener- 
ally takes the form of an acute mania, sometimes a melan- 
cholia. The attendants are generally forewarned of an 
outbreak by the unnatural, moody behavior of the patient. 
The management of the case consists chiefly in care and 
watchfulness to prevent the patient from injuring herself 
and others, and nourishment and attention to general 



240 



LABOR 



health. The baby should be taken from the breast and 
removed from the presence of the patient as soon as the 
condition is discovered. A large majority of the cases 
recover if managed properly, but the condition may last 
many weeks or months. 

Difficult Micturition. — After labor patients frequently 
have difficulty in micturition, that is, in passing urine. 
This difficulty may be due perhaps to the lessened power 
of the abdominal muscles or to injuries to the urethra 
and base of the bladder during labor, with subsequent 
swelling and spasm of the bladder. It is likewise increased 
by the fact that the patient must urinate while lying on 
her back — an unusual position for her. Overdistention 
of the bladder, always to be avoided, is particularly 
harmful after labor. It may lead to a long-continued 
paralysis of the bladder muscle or to injury of the mucous 
membrane of the bladder, a condition which predisposes 
to infection. It also interferes with contractions of the 
uterus and thus favors postpartum hemorrhage. Hence 
the nurse should be on the watch for an overfilled bladder, 
especially as the patient is frequently unconscious of it. 
Sometimes a little urine overflows from a distended bladder 
deceiving both patient and nurse. With a little practice 
this condition can be determined by examining with the 
hands and finding a soft mass above the pubis in front of 
the hard, contracted uterus. The uterus is frequently to 
one side and the bladder to the other side. Should there 
be any doubt whether a swelling in this location is bladder 
or bowel, percussion would easily show the difference 
between the dull sound of the full bladder and the sound 
produced by a distended intestine. Sometimes the bladder 
fills very rapidly after labor, and in the course of three or 
four hours extends nearly to the navel. Perhaps the 
patient did not pass her urine for some time before the 
child was born. In such cases the bladder should be 
emptied as soon as the condition is discovered, otherwise 
the patient may wait six, eight, or ten hours. Rarely 
should the nurse delay longer than twelve hours after 



DIFFICULT MICTURATION 



241 



labor and then only if she be quite certain that the bladder 
is not overfull. 

It is always better for a patient to pass her urine than 
to have it drawn with a catheter. When a laceration 
has occurred, fear is sometimes expressed that urine 
flowing over the sutured wound may interfere with the 
healing. This fear is due to the not uncommon but 
erroneous idea that urine is in some way very poisonous. 
Urine from a healthy bladder is quite sterile and of course 
can cause no infection. It is not particularly irritating, 
and if the parts are washed off, as they should be, imme- 
diately after urination or even during urination not the 
slightest harm can be done. 

If the patient cannot urinate while lying on the bed- 
pan she may sometimes be helped by pressing with the 
hand over the bladder or by such well-known expedients 
as using hot fomentations over the pubes, hot water in the 
bed-pan, letting water run from a faucet and from a 
pitcher. Sometimes a patient can urinate after an enema 
while emptying the bowel. All these measures, however, 
are often futile, and then it may be necessary for the 
patient to rise to the sitting posture. It will be found 
that the easiest position for the patient is when she is 
kneeling with the chamber-pot between the knees and 
legs. She throws one arm over the shoulder of the nurse, 
who sits partly behind her and supports her with an arm 
around her body. As this is the position that the patient 
may have to take when her bowels move, it is desirable 
that the nurse know exactly how to bring her patient 
into this attitude easily and support her securely. 

Of course if the patient is very weak from any cause, 
and particularly if she has lost much blood, this treatment 
would not be employed. In normal cases, however, no 
harm will result. Some physicians prefer to have the 
patient get out of bed. Many might object, however, 
to having a patient sit up, and therefore it would be well 
in case the nurse does not know the ideas of the attending 
physician in this regard to ask him whether she shall 
16 



242 



PUERPERIUM 



catheterize the patient, in case micturition is impossible, 
in the horizontal position or if the sitting posture should 
be tried. 

When for any reason it is not desirable that the patient 
should be raised from the horizontal position or when she 
cannot urinate even sitting it becomes necessary to 
catheterize her. Here the nurse is obliged to assume a 
grave responsibility. The great majority of cases of 
cystitis or inflammation of the bladder have been caused 
by the catheter. There are two dangers in catheteriza- 
tion: (1) injuring the bladder wall, and (2) carrying 
infectious germs into the bladder. By the careful use of 
a smooth-glass catheter, which is the only kind to be 
employed by a nurse, there is not much danger of a severe 
injury to the bladder; yet it may often happen that a 
contraction of the neck of the bladder upon the introduc- 
tion or the withdrawal of the instrument may cause some 
injury to this region in spite of the best technique. 
Undoubtedly the great danger is that of infection. Even 
if the catheter is made absolutely sterile by boiling, which 
should always be done, the frequent presence of large 
numbers of bacteria around the mouth of the urethra, 
often penetrating a third of an inch into the canal, makes 
it very hard to avoid carrying them into the bladder. 
The following rules should be strictly followed: (1) 
disinfect the hands; (2) boil the catheter; (3) disinfect 
the genital region as already described, using the irrigator 
and having the patient in a good light; (4) separate the 
small lips with one hand so that the mouth of the urethra is 
clearly seen, and with the other hand thoroughly douche 
the vestibule with quantities of sterile water, directing 
the stream so as to wash out the mouth of the canal; 
(5) substitute for the irrigator-point the catheter, insert 
it into the urethra about a third of an inch and let the 
water run for a minute, then leaving the catheter in the 
urethra, disconnect the tube and push the catheter into 
the bladder (no lubricant is required) ; (6) when the urine 
ceases to flow in a stream, without waiting until the last 



CONSTIPATION 



243 



drop is expelled, remove the catheter and once more 
wash off the vulva with the irrigator. Where the irrigator 
is not used the vestibule and mouth of the urethra are 
cleaned with sponges, after which the catheter is intro- 
duced without using it first as a douche-point to wash 
out the bacteria from the urethra. 

Frequently one catheterization is all that is required, 
the patient being able to empty the bladder afterward. 
If the catheter must be used for several days the danger 
of infection is much increased, because it is very natural 
for the nurse to relax in her efforts. Conscientious 
thoroughness is here of great importance. 

The nurse was formerly taught to catheterize "by the 
touch" or "under the sheet." The mouth of the urethra 
was found through the sense of touch by the fingers of 
one hand and the catheter, held in the other hand, pushed 
into the bladder. It was considered a great feat and almost 
a test of a good obstetrical nurse to be able to find the 
right opening and carry the catheter into it without first 
pushing it into the vagina or perhaps the rectum. The 
false modesty that dictated this foolish practice has now 
been driven away by the general spread of the knowledge 
of germ diseases, and the practice is only mentioned to 
be condemned. 

For the first week the quantity of urine passed by the 
patient should be estimated or measured and recorded 
on the history sheet. 

Constipation. — The majority of women in childbed 
are constipated. The chief factors that bring this about 
are fecal retention during pregnancy, the causes of which 
are discussed in Chapter III, the frequent lack of coarse 
food in the diet, the absence of exercise, the horizontal 
position of the patient, and the lax abdominal walls. 
The degree in obstinancy of the constipation varies much 
with different patients. Sometimes a regulation of the 
diet, a dose of salts, an ounce of liquid petrolatum, or a 
simple enema are all the measures that are required. 
In other cases of long-continued constipation with large 



244 



PUERPERIUM 



accumulations in the intestine, the management of the 
bowels may be the most difficult part of the nurse's duty 
in the care of the case. The patient should have an 
evacuation of the bowels every day, including the first 
day of labor. For the guidance of the physician the nurse 
should always report fully not only the number of bowel 
•movements but also their character, the amount of diffi- 
culty experienced in defecation, and also between the 
bowel movements the amount of gas in the bowel and the 
amount of discomfort arising from it. 

The measures employed by the nurse to relieve consti- 
pation and its attendant discomforts are massage and 
enemata. In performing massage it is necessary to 
remember the course of the large bowel. Starting in the 
lower part of the abdomen near the middle of the right 
groin, it passes up to the liver under the ribs as the ascend- 
ing colon, crosses to the left side as the transverse colon, 
and descends to the left groin as the descending colon, 
terminating in the sigmoid flexure, which ends within 
the pelvis in the rectum. In the lax condition of the 
abdominal walls after labor it is reached more readily 
than at any other time. Much of it is covered by the small 
bowel, especially where the latter is at all distended with 
gas. The portions of the large bowel most readily acces- 
sible are the beginning of the ascending colon, the middle 
of the transverse colon, and the lower part of the descend- 
ing colon. Massage acts in two ways: (1) the contents 
of the bowel, liquid or solid, are moved along mechani- 
cally, and (2) the worm-like or peristaltic movements 
of the intestine are stimulated. When massage is com- 
bined with an enema the liquid is first carried backward 
to the beginning of the colon by the reversed movement 
and then forced out again. By keeping in mind the loca- 
tion of the colon and the object of massage an intelligent 
nurse with a little practice can do fairly well even without 
special training in the technique. The manipulations 
which are executed over the accessible portions of the 
colon may be made with the ball of the thumb or the 



CONSTIPATION 



245 



outer side of the hand or with the fingers, the skin moving 
with the hands. Pressing over the abdomen with the 
hand during defecation may also be of value in forcing 
along the contents of the colon. 

The enemata employed in childbed are of various 
kinds. The amount may vary from 1 dram to 3 quarts. 
Plain water or glycerin or oil may be used, and also various 
water solutions of common salt, Epsom salts, soap, 
turpentine, glycerin, etc. The injection may be cold, 
tepid, or warm. Injections of 1 to 4 drams of glycerin or 
glycerin and water may be given with a small glass or 
hard-rubber or piston syringe; larger amounts are generally 
given with the fountain syringe. The rectal point, whether 
of glass or of hard rubber, should be smooth and clean. An 
old, cracked, hard-rubber point or one with a rough end 
might cause an abrasion of the mucous membrane while 
being pushed, perhaps roughly, through the sphincter 
ani and lead to an infection or an obstinate wound. For 
this reason some prefer to use always a soft-rubber tube 
that has two opposite, smooth side-openings or eyes about 
one inch behind the somewhat blunt, taper-pointed end. 
It should be coated with a clean lubricant. 

The amount, kind, and temperature of the injection 
should be specified by the physician. If a patient suffers 
with considerable gaseous distention of the bowels an 
injection of 1 ounce of glycerin, 1 ounce of magnesium 
sulphate, and 4 to 6 ounces of water is frequently ordered. 

Sometimes the rectum and sigmoid flexure are stopped 
up with an impacted mass of feces that cannot be washed 
out with an injection. Here it will be necessary to insert 
the finger, well lubricated and protected with carbolized 
vaselin, or, better, with a glove, and break up the mass 
little by little, using the irrigator with soap solution, 
from time to time, to wash away the loosened particles. 

When there is an accumulation in the colon the so- 
called colonic washing or lavage is indicated. This may 
be given in the following way: The bed being protected 
with rubber sheets and pads and the bed-pan being at 



246 



PUERPERIUM 



hand, the pelvis is raised so that water may run into the 
bowel by lifting the foot of the bed. Normal salt solution, 
one level teaspoonful to a pint of water, or a soap solution, 
both at a temperature of about 70°, is used. The end 
of a large soft-rubber tube, about No. 30 of the French 
scale, connected with the irrigator, elevated one or two 
feet above the patient, is introduced three or four inches 
into the rectum and the water allowed to run. No attempt 
should be made to carry the tube into that portion of the 
bowel that lies above the promontory or inlet of the pelvis. 
The tube will simply coil around in the gut. When the 
patient begins to feel uncomfortable the flow is stopped, 
the rectal tube disconnected and allowed to empty into 
the bed-pan; then this procedure is repeated four or five 
times. Not all of the water returns through the tube 
each time the rectum is emptied, but some of it remains 
in the colon, and finally a sufficient quantity has passed 
to stimulate thoroughly the peristalsis and effect a good 
evacuation. If this washing is repeated once or twice 
a day for several times the entire colon will be well emptied 
without the disturbance caused by the use of the usual 
large tepid enema. 

Diet. — As a rule the physician gives directions concern- 
ing the diet of the patient in childbed. As in so many 
other questions not obstetrical, there also exist here 
antiquated and unfounded notions, so that it is desirable 
for the nurse to know the principles of dietetics in order 
that she may be able to assume safely whatever responsi- 
bility is thrown upon her. 

There are prevalent two common erroneous ideas 
concerning the diet of women in childbed: One is that 
hearty food, especially meat, etc., will cause fever. There 
is, of course, absolutely no basis for this notion. The 
cause of fever is infection from some source, in the great 
majority of cases from genital wounds or from breast 
wounds. Indigestible food, like salads or pickles, may 
distress the stomach and make the patient uncomfortable, 
but only in that way can the food harm her. 



DIET 



247 



The other common error is that very many foods injure 
the milk secretion and harm the nursing infant. Particu- 
larly are sour substances like fruit thought to be harmful. 
About all the exact observations that have been made on 
this subject, however, tend to discredit this popular 
notion. Even pickles and salads, which may be harmful 
because they produce indigestion, have no effect on the 
demonstrable chemical composition of the milk nor on 
the nursing child. 

Hence the problem of feeding the mother does not 
differ from that of feeding any other individual under 
similar conditions. Food is for the purpose of replacing 
the outgo of the body, including both the waste and the 
secretions and creating heat and motion. The outgo 
from a woman in childbed includes the loss from the 
ordinary excretions and also from the hemorrhage, lochia, 
and the breast. During labor a woman loses in the child, 
fruit-water, blood, and perspiration one-tenth of her 
weight, and within one week after labor about one-half 
as much more in the lochia and excretions. Hence we 
see the necessity for a liberal diet if the patient shall 
make up for this loss. Moreover she must supply from 
one to three pints of milk a day. On the other hand she 
has no great waste of heat, for she is covered in bed and 
there is very little expenditure of energy in motion. 
The conclusion drawn from these facts as well as from 
clinical observation is that the diet for a nursing woman 
in childbed should not differ essentially from the mixed 
diet proper for a woman during pregnancy. 

The proper mixed diet for a person not engaged in 
much muscular work is one that contains about 3 ounces 
of solid proteids, 2\ ounces of pure fat, and 10 ounces of 
carbohydrates, that is, sugar and starches, with 3 to 4 
quarts of water. About \\ to 2 quarts of water are con- 
tained in the food, including fruits, soup and milk, while 
1 to 2 quarts are drunk as a beverage. A simple dietary 
for a day may be given as an example: 

On wakening, about 7 a.m., a cup of hot milk. 



248 



PUERPERIVM 



Breakfast, 8.30 to 9 a.m. Fruit: apples, oranges, 
pears, grapes, etc. Coffee with cream, oatmeal and 
cream, eggs, toast, and butter. 

1 p.m. Fruit, chopped beef or steak, potatoes, pens, 
toast, butter, tea with cream. 

Dinner, 6.30 p.m. Soup, chicken, rice, toast, butter, 
pudding, etc., coffee. 

Any diet is to be arranged to suit the needs, the con- 
dition, and the appetite of the patient. For the first 
day it usually happens that she has no appetite for 
much solid food, but craves quantities of liquid. This is 
because of the great loss of water during labor from 
perspiration and perhaps from hemorrhage. This desire 
should 'be gratified and solid food not forced on the 
patient. If, however, she is hungry and wishes a 
hearty meal immediately after labor, there is no reason 
why this wish should not be gratified. To force a liquid 
diet upon a patient who has no need for great quantities 
of liquid is as unwise as to force solids upon a patient 
who needs liquids. The same remarks apply to some 
extent to different articles of diet and especially to the 
use of alcoholic drinks. A patient who is accustomed to 
the use of beer or wine with her meals may suffer from 
their withdrawal, while to force such drinks upon one who 
has never used alcoholic drinks with the idea that they 
are specially needed is equally unwise. One must use 
common-sense, seeking only to give enough food to supply 
the needs of the individual, trying to combine the food 
elements approximately correctly and avoiding sub- 
stances known to be difficult of digestion. 

The questions frequently arise (1) whether the quantity 
of milk may increase or diminish by diet, and (2) whether 
the quality can be so changed. The amount of milk is 
diminished by greatly lessening the quantity of food, 
while free feeding frequently increases the milk secretion. 
A decrease in the quantity of milk is very rarely desired 
except perhaps during the short period of breast conges- 
tion that occurs during the third to the fifth day. While 



DIET 



249 



there may be no objection to a restriction of the diet at 
this time, still such restriction is hardly necessary, for 
the disturbance may be managed without difficulty by 
the rules given on page 253. 

The best way for a nursing mother to increase the 
supply of milk is to eat plenty of nourishing food. The 
common idea that taking much liquid will increase the 
milk is largely erroneous. Too little water may interfere 
with the secretion, but milk is formed from the solid 
elements of the food, and they are absolutely essential. 
Beer, malt extracts, etc., which are much renowned as 
galactagogues or milk producers, probably owe their 
reputation to their property of stimulating the appetite 
and thus inducing a better nutrition. Of the solid elements 
of food it is probable that the protein or nitrogenous 
element is most important in producing milk. It has 
been proved that all the elements of milk, including the 
fat, may be produced by the breaking up of the protein 
particles. The fat of milk, for example, does not come 
from the fat of food, but from the proteins of food. For 
this reason pure albumins have been used as milk-producing 
agents and much advertised on this account. 

There is a limit to the quantity of food that can be 
taken with advantage. If a woman who is underfed 
secretes too little milk, increasing her food consumption 
will probably increase her milk. A well-fed woman will 
not be so affected. If she has a deficient secretion it is 
probably due to some deficiency in the structure or 
function of the breast not dependent on her eating. It 
is unwise to feed such a patient more than she needs in 
the attempt to increase the supply of milk. Even when 
some increase in food increases the milk it does not follow 
that the increase can be continued indefinitely. Over- 
feeding a patient is always worse than useless. 

The quality of the food and the method of serving it 
have an important effect on the breast secretion. Not 
only is the appetite stimulated by savory, well-prepared 
food and a greater quantity is taken without forcing, but 



250 



PUERPERIUM 



also the nervous control of the secretion seems to be 
affected just as the nervous mechanism of the salivary 
and gastric secretions is affected. Hence the nurse should 
get the cooperation of the cook in preparing the food, 
and then see to it that the meal is served properly. 

The question whether the properties of milk can be 
changed by varying the composition of the mother's 
food cannot at present be answered definitely, for suffi- 
cient scientific observations have not been made to give 
any basis of fact. If it were possible to increase the fat 
of the mother's milk, for example, or to decrease the albu- 
min of the milk when this element is in excess by changing 
the diet, such a food would be of very great value. It 
can only be said that an average mixed diet is best adapted 
to give milk of proper composition. 

The frequency of feeding or the number of meals per 
day is a question that often arises. If the stomach be 
in a normal condition the ordinary rule of three meals 
a day, with perhaps a drink of hot milk early in the morn- 
ing, is the best rule to adopt. If the patient wants a light 
lunch late at night or between meals it may be allowed. 
The case is different if the stomach is unhealthy — a con- 
dition not uncommon. One of the abnormalities most 
frequently met with is the dilated, prolapsed stomach. 
Such an organ does not empty itself properly and the 
partly digested remaining food ferments and causes a 
very disagreeable sensation. Putting additional food 
into such a stomach would evidently add to the trouble. 
The common-sense rule in such a case would be to give 
food only after the stomach is emptied. 

In such cases it is often of much value to assist the 
emptying of the stomach by a simple kind of massage. 
About two to three hours after meals, when the movements 
of the weakened stomach have become feeble, the nurse, 
standing beside the patient, facing the foot of the bed, 
grasps with both hands the abdomen so as to get below 
the stomach and raise it, making kneading movements 
to empty its contents into the small bowel. The patient 



LACTATION 



251 



may incline slightly toward the right side. This maneuver 
may be assisted by having the patient drink a small 
quantity of some carbonated water. This procedure is 
kept up for five minutes and may be repeated in half an 
hour if necessary. It would be unwise, however, to empty 
at one time too large an amount of the acid contents of 
the stomach. 

In all these cases it is important that the patient does 
not drink large quantities of liquid with her meals or 
shortly after them. The rule should be to drink what 
is needed fifteen to thirty minutes before meals. Careful 
management of the stomach is very necessary for the 
satisfactory progress of the patient and particularly for 
the proper milk supply of a nursing mother, and hence 
requires the most intelligent attention of the nurse. 

Breasts. — Nearly every woman in childbed requires 
that some attention be paid to the breasts. More than 
half of all nursing women have abrasions of the nipple 
of greater or less extent. These, if neglected or improperly 
managed, may lead to infection of the breast with abscess 
formation, much suffering, and great injury. Moreover, 
when the breasts become diseased the children lose their 
proper nourishment and as a result much sickness and many 
deaths occur. Hence no subject is of greater importance to 
nurses than that of the proper management of the breasts. 

How often and how long at a time an infant shall 
nurse concerns both mother and child. Considering now 
only the mother, we observe that if the infant nurses too 
often or too long the mother loses her rest, wastes her 
strength, and becomes exhausted. Moreover, if the child 
holds the nipple very long in the mouth it becomes softened 
and more easily wounded and infected. When speaking 
of the care of the child we shall give rules on this point; 
here we shall only remark that ten to twenty minutes are 
about the proper length of the nursing, and once in two to 
three hours is often enough. 

Colostrum. — For from one to three days after labor the 
secretion of the breast has not the composition of ordinary 



252 



PUERPERIUM 



milk. This first secretion is called colostrum. The 
quantity of colostrum that the child can get by nursing 
varies from one or two drams to an ounce. It is very 
important that the infant obtain this colostrum both 
because it has considerable value as food and because it 
has a certain laxative effect that is good for the child. 
Moreover, the act of nursing is important for the mother 
because it stimulates the contraction and retraction of 
the uterus and thus tends to prevent hemorrhage and 
assists in the proper involution of the uterus. Also the 
stimulation of the breasts by the act of nursing favors the 
beginning of the secretion of milk, so that the milk "comes 
in" earlier and with less disturbance than when the child 
is kept from the breast. Therefore the child should be 
put to the breast as soon as it is cared for and dressed, 
unless the mother be very weak from hemorrhage or the 
exhaustion of labor. For the first two or three days 
the child may nurse every three to six hours, according 
to its condition and that of the mother. The remark 
frequently heard, that the mother has no milk, need not 
be regarded too seriously, for it is not milk that we expect 
the child to obtain. The child will generally get some 
breast secretion, that is, colostrum, even when the breast 
seems empty to the superficial observation of the patient 
and her relatives. 

Distention of the Breast. — Gradually this first secretion 
changes to the ordinary milk and generally the third 
day the breasts begin to fill. This condition of fulness 
or distention of the breast, also called congestion or 
engorgement, is frequently attended with considerable 
pain. It is important that the nature of this condition 
be well understood. Many nurses believe that this dis- 
tention of the breast is caused by the milk which fills 
the milk tubes or ducts, and there is a general fear that this 
milk may stagnate and, if not emptied, cause caked or 
inflamed breasts. This conception of the cause of disten- 
tion is largely false and the fear entirely groundless. 

The distention is caused largely by the swelling of 



LACTATION 



253 



the gland cells that are secreting the milk and by the 
fulness of the blood and lymph vessels and the lymph 
spaces that surround the glands. If these vessels be 
emptied by massage, as will be described later, the disten- 
tion of the breast disappears although not a drop of milk 
has been evacuated. Moreover, decomposition of milk 
in the healthy breast never occurs. 

Sometimes a woman cannot or should not nurse, as 
when the child is dead or when she has tuberculosis or 
some serious disease that would make the drain of nursing 
a menace to the life of the mother. Here the breasts 
should be supported by bandage and relieved by massage 
or ice-bags, and in a short time the congestion of the vessels 
will disappear while the milk in the ducts will be absorbed, 
leaving no bad effect. 

These facts show that congestion of the breast, however 
painful, is not dangerous and should give rise to no anxiety. 
It should be carefully distinguished from the results of 
infection of the breast. The filling of the breast is never 
attended with fever, that is, with a rise in the temperature 
of the body to 100°. The breast may be very tender, 
hot, hard and swollen, but the thermometer in the mouth 
or rectum shows no fever. 

The management of distention of the breast has for 
its object the relief of the local pain. Four measures 
will be considered: (1) evacuation of the breast with the 
hand or breast pump, (2) support by bandage, (3) appli- 
cation of ice-bag, and (4) massage. 

Pumping. — Evacuation of milk either by milking with 
the hand or by the use of the breast pump will often give 
temporary relief. It is objectionable because both the 
hand and pump cause irritation of the breast, because the 
stimulation of the breast by these measures is not desir- 
able, and because it is not necessary. Whatever relief 
is given by the nursing of the child is of course desirable. 
It may be necessary to obtain milk to feed a very weak 
child that cannot nurse; otherwise, if the following direc- 
tions for supporting and massaging the breast are carried 
out, no pump will be needed. 



254 



PUERPERIUM 



Bandage of Breast. — The support of the breast is an 
important means of relief. Pain or disturbance of the 
full breast is caused chiefly by the dragging down of the 
healtliy gland as the woman lies on her back. She may 
not be able to lie on her side because of the pressure on the 
lower breast or for other reasons. The glands may be 
supported from below by pillows pressed against the sides, 
but better by bandages which hold them in place. The 



Fig. 89 




Breast bandages. 



object of the bandage is support and not compression. 
It must be applied so as to give relief and not cause more 
pain. This will be accomplished if it is applied so as to 
hold the breast to the front of the chest. 

The simplest bandage is most easily applied and quite 
satisfactory. It is a piece of strong cotton cloth long 
enough to go around the body and lap sufficiently to pin 
in front. It should be about sixteen inches wide with 



LACTATION 



255 



notches seven to eight inches deep for the shoulders over 
which the edges of the notches are pinned. It is applied 
as follows: The patient should lie on her back near the 
edge of the bed, the bandage under her, its notches fitting 
well in the axillse. The nurse now takes hold of one end 
of the bandage with one hand and with the other hand 



Fig. 90 




Application of breast bandage. 



draws up the breast quite well to the front of the chest, 
where it is held by the bandage. Then the patient with 
a hand under the breast, fingers and thumb being extended, 
holds it in place. The other breast is drawn up and sup- 
ported in the same way. Then the bandage is fastened 
with five medium-sized safety pins, the lower edge of the 
bandage being drawn perhaps a little tighter than the 



256 



PUERPERIUM 



upper edge. The flaps are then fitted well over the 
shoulders. This bandage of course must be opened every 
time the child nurses and afterward reapplied. 



Fig. 91 




Breast and abdominal bandages applied. 



Sometimes the double Y-bandage is preferred. It is 
made out of the strongest cotton cloth and consists of 
a back piece four to five inches wide and fourteen to 
twenty inches long, to each end of which is strongly sewed 
two diverging strips, each four to five inches wide and 
about twelve inches long. The lower limbs of the Y s, 
which go under the breast, are fastened together in front 
with safety pins, then the upper limbs in the same manner. 
With this bandage the nipples are left free so that pressure 
upon them is prevented and the nursing of the child 
allowed without unfastening the bandage. The upper and 
lower limbs of the Y's in front may be fastened together 
with a safety pin to better support the inside of the 
breast. 

The roller bandage for the breast may be used in cases 
of infection where permanent support and some com- 
pression are wanted. It may also be used when the mother 
does not nurse because of the death of the child or for 
some other cause. 

We will first describe the bandage when only one, for 



LACTATION 



257 



example, an inflamed breast, is enclosed. A roller three 
inches wide and ten to twelve yards long is required. 
Both breasts are covered smoothly with absorbent cotton, 
and a small pad of cotton to protect the shoulder of the 
opposite side is in readiness. Beginning outside of and 
below the affected breast, the bandage is carried twice 
around the chest, passing under the well breast first; then it 
is carried under the affected breast and over the shoulder 
of the opposite side, back under the breast and again 
around the chest, and then a second time over the shoulder. 



Fig. 92 




Double Y-bandage. 



Then it passes again under the breast, the lower half of 
which is now nearly covered, and around the chest above 
the well breast. The next turn comes directly over the 
nipple of the inflamed breast and above the well breast. 
Two or three turns then cover the remainder of the affected 
breast. If any bandage remains and a particularly firm 
support is desired, a turn may be again made under the 
breast and over the shoulder and still another under the 
affected breast and above the well one, finishing with an 
extra turn over both breasts. This bandage must be well 
17 



258 



PUERPERIUM 



fastened with twelve to twenty safety pins, placed in 
front, behind, and at the sides. Finally the extra cotton 
over the well breast may be removed or an opening made 
for the child to nurse. 

If both breasts are to be enclosed, five or six yards 
more of bandage will be required. Begin with two turns 
around the body and one turn under the first breast and 
over the opposite shoulder as before. The bandage is then 
carried under the second breast and over the back across 
the shoulder opposite the second breast, down in front 
and under the breast again; then it goes around the body 
under the first breast, across the front part of the chest, 
over the shoulder, under both breasts again and across 
the back and over the shoulder opposite the second breast, 
and again under the second breast. This turn may be 
repeated a third time if necessary. Then the bandage 
is brought under the first breast, now nearly half -covered, 
above the second breast, across the back, above the first 
breast, under the second breast, forming a figure-of-eight 
around the breast. This may be repeated if necessary 
and then the bandage is fastened with two turns around 
the chest over both breasts. This breast bandage must 
also be fastened with numerous pins. 

It is convenient to make the first turn with the patient 
on her back and have her sit while applying the rest. 
Much care should be taken to try and bandage just tight 
enough, and on this account the patient should be asked 
frequently if it be comfortable. If the bandage is too 
tight, it will draw heavily upon the shoulders and become 
unbearable. 

Ice-bags. — If the breasts are very sensitive and not 
sufficiently relieved by the bandage, ice-bags should be 
applied. The large, strong, vulcanized canvas bags are 
more desirable than the rubber bags and can be fitted 
better to the breast. The axilla and arm should be pro- 
tected by cloths. If the tender part of the breast is on 
the lower or outer side, the bag is applied and held in 
place by shoulder pillows. If the upper, middle, or inner 



LACTATION 



259 



part of the breast is chiefly affected, the bag is then applied 
and held to the bandage with strings or safety pins. 
The patient must be in bed, of course, and the breast kept 
supported with the bandage. 



Ice-bags applied to breasts. On the right breast is a large, strong, vul- 
canized, canvas cap-bag supported by a pillow, and on the other a pig's 
bladder fastened to the breast bandage with safety pins. 



Massage of the Breast. — Massage of the breast is a 
measure which has been so often misused that it is a 
question whether it has not caused more harm than good ; 
yet, if it be properly done in suitable cases it may be of 
great value. It should be used only in cases of painful 
distention due to congestion, and never in cases of infec- 
tion. The proper method of making massage will now 
be considered. 

The common method of performing massage is incorrect 
and founded upon a false principle. The direction is 
generally given to rub the breast from the outside toward 
the nipple, as if the intention were to evacuate the milk 



Fig. 93 






260 



PUERPERIUM 



or perhaps open up some occluded milk duct. This is not 
the object of massage at all. The blood and lymph 
channels and spaces of the tender, congested breast, like 
those of a sprained joint, are overfilled with blood and 
lymph. Just as in a sprained joint the surgeon begins 
on the inner side of the swelling and empties out the 
excessive fluid by rubbing toward the heart, gradually 
approaching nearer and nearer to the joint until the swell- 
ing and tenderness are gone, so here, beginning outside of 
the breast, we empty first the vessels which lead from it, 
and then approaching the gland itself rub always so as to 
favor the carrying away into the circulation of the extra 
fluids. To understand the details of the operation, how- 
ever, it will be necessary to study for a moment the 
anatomical arrangement of the blood and lymph vessels 
of the breast. Both glands are composed of fifteen to 
twenty separate secretory systems (see p. 52), each of 
which consists of a main duct which divides and sub- 
divides until we come to a last group of distended acini 
lined with a special kind of cells that secrete the milk. 
The ends of the tubes form the gland proper. Around 
the gland lobules the lymph routes form a network and 
empty into channels that run along and surround the 
milk ducts. These are joined somewhere near the outside 
of the areola by ducts coming from the nipple. From 
this juncture channels pass down under the breast along 
its floor outside and upward, joining with other lymph 
ducts until they finally pass into the axilla and empty into 
the chain of axillary glands. The blood capillaries that 
surround the gland lobules pass into venules that follow 
a course similar to the lymph ducts, passing away from 
the breast in deep vessels to empty into the large vessels 
of the axilla and the lower front part of the neck. 

From this description of the structure of the breast, 
it is evident that to massage it properly it is necessary 
to begin outside and above the gland and then work under 
the gland as much as possible before touching the breast 
itself. The operator or nurse should sit on the side of 



L ACT AT I OX 



261 



the patient opposite to the breast to be treated — for 
example, upon her right side if the left breast is to be 
treated. In this case the patient would lie upon her right 
side with her left arm somewhat raised, supported upon 
a pillow behind her. The nurse begins by rubbing at 
first superficially and then more deeply with the palmar 
surface of the thumbs or hands. In the deep rubbing she 
must remember that the skin is not to be rubbed, but 



Fig. 94 




Massage of the breast. 



carried along with the thumbs over the deep tissues. After 
the region surrounding the gland has been sufficiently 
treated, she rubs in the same direction as far as possible 
under the gland; then the gland itself may be massaged. 
Recalling the course of the lymph and venous routes and 
small vessels from the outside of the gland toward the 
circle outside of the areola, she rubs with very gentle 
movements in the same direction, using the ends of the 
fingers. In connection with these movements kneading 



262 



ITKRPERIUM 



manipulations tending to empty the channels under the 
breast are combined. 

With soft hands and well-regulated pressure, all this 
may be done without the use of any lubricant. It is 
better, however, to use a solution of soft soap. Unless 
the patient is relieved without much pain the massage 
is not properly given and should be discontinued. When 
rightly and successfully given, in the course of fifteen to 
twenty minutes the previously swollen and very sensitive 
breast is flaccid and relieved. 

Infection of the Breast. — Having now considered the 
matter of the congestion of the breast, let us turn to the 
very important subject of the infection of the breast. 
Mastitis, or inflammation of the breast, is the term gen- 
erally employed to denote the condition which results 
from infection. It should not be forgotten that stagnation 
of milk does not cause an inflamed breast. Only the pres- 
ence of bacteria growing into the gland tissue can cause 
fever and the other symptoms of infection. 

The bacteria generally found in breast infection are 
the staphylococci or those which grow in the cluster 
arrangement. Sometimes the chain bacteria or strepto- 
cocci are found. 

It is now generally agreed that breast infection starts 
from the nipple. The question arises, How do the bac- 
teria get to the nipple? 

All regions of the skin are covered with bacteria. The 
number is especially great around the nipple of the 
pregnant woman because of the good soil furnished by the 
secretion which exudes to a greater or less extent. Some- 
times a kind of crust forms over the nipple that contains 
numberless germs. Hence, if the nipples are not properly 
cleaned before nursing, the germs are there already, 
prepared to grow upon any abraded or injured surface. 

In this connection we may speak of an infection from 
a source not very common, but yet quite important, 
namely, suppurating Montgomery glands. These small 
glands around the nipple sometimes become infected 



LACTATION 



263 



during the nursing period, and thus a source of danger 
to the nipple. 

If the germs present on the breast be removed by careful 
washing before the first nursing, the nipple may afterward 
become contaminated from several sources. Articles 
of clothing, especially the shirt, may be the source of 
contamination. Freshly washed clothing is practically 
sterile, but after it has been worn a few hours it contains 
many germs, and in twenty-four hours it is well saturated 
with bacteria. The fingers of the patient or nurse may be 
the carriers of infection, especially if the common practice 
of pulling out the nipple, so that the baby may better 
grasp it, is resorted to. When the nurse fails to disinfect 
the hands after handling the napkins of the baby or mother, 
this source of danger may be important. Then the child 
may be the cause of trouble. Sometimes the mouth may 
contain dangerous germs, but generally the mouth becomes 
contaminated from the breast. The baby's face rubbing 
over the breast is more frequently the origin of the trouble. 
If the baby has sore eyes or pustules or boils on the face 
or head, we can readily see how the skin may become 
contaminated. 

The presence of germs alone cannot cause infection 
of the breast. There must be a break in the epithelial 
covering of the nipple. This fact shows the importance 
of the form, size, and structure of the nipple and the 
detrimental influence of deformed nipples. A nipple 
perfect in shape and size, so that it may be easily grasped 
and through which the milk flows freely, is much less 
likely to suffer abrasions from the suckling than one that 
is lacking in any of these characteristics. If the nipple 
is small or depressed the child must grasp it more firmly 
and thus injure it. A so-called cracked nipple results 
from the formation of a fissure or the injury of a natural 
fissure by the act of nursing. The fissure may be parallel 
to the nipple or at right angles to it. Such fissures are, 
of course, especially dangerous points of entrance for the 
infection. 



264 



PUERPERIUM 



/ 



When the secretion is slow and scanty the suction 
required and the length of the nursing will be greater, 
as well as the risk of injury and infection. This strong- 
suction, for example, produces blisters, varying in size 
from the head of a pin to that large enough to cover the 
end of the nipple. The supply of milk and the ease of 
its flow thus become important factors, determining 
infection. 

A further factor influencing infection and determining 
its extent is the resistance of the maternal organism. 
This is a factor in all infections, and depends upon the 
general health and the immunity to the attacks of the 
germs likely to be found in the contaminating material. 

The mode of growth of the infecting microbes does not 
differ essentially from that in genital or other wounds. 
The germs may remain confined to the abrasion or fissure 
of the nipple, causing some redness and perhaps some 
discharge ; or they may penetrate deeply into the gland or 
they may pass under the gland, or, lastly, they may grow 
over the breast and under the skin. The last mode of 
growth is characteristic of the chain bacteria or strepto- 
cocci. When the germs penetrate the breast it is a peculiar 
fact that they generally follow one or more ducts with 
their ramifications and make a circumscribed hardness 
that may terminate in abscess. When the infection is 
confined to the nipple there is not much general disturb- 
ance as a rule. A chill with fever, headache, etc., generally 
denotes extension of the infection into the breast. It 
does not, however, mean that an abscess is unavoidable. 
In eight or nine cases out of ten the formation of pus may 
be prevented if proper treatment be instituted. 

Although this differential diagnosis between infection 
of the breast and simple congestion concerns the physician 
much more than the nurse, it is, however, well for her to 
know that the presence of fever due to the breast shows 
infection. Whether an abscess is formed or not is, of 
course, a question for the doctor to settle. 

From what has been said concerning the cause of infec- 



LACTATION 



-I'm 



tion, it is evident that it may be prevented if we can 
prevent the access of the infecting microbes or if we can 
avoid the abrasions or breaks in the epithelial covering 
of the nipples. The latter is often impossible, because of 
some deformity in the nipple or because of the character 
of the skin. If there is a wound of sonic extent, like a deep 
fissure, a protecting shield may be used, but the danger 
from small, often unobserved abrasions remains. In pre- 
venting the access of germs, as long as the nurse is in 
attendance she has great responsibility. 

Before labor something can be done to get the breasts 
in a proper condition. The main thing is to keep the 
nipples clean and toughen them so that they will not 
become sore. The use of salves or of tannin solutions, as 
frequently advocated, is generally unnecessary and possibly 
harmful. Exciting the nipple in any way before labor 
may cause uterine contractions and has produced mis- 
carriage or premature labor. The efforts to draw out a 
depressed or retracted nipple do not do much good. The 
best advice to a woman during pregnancy is to keep the 
breast as clean as other parts of the body by the use of 
soap and water, and in the last two or three weeks rub 
the nipple rather thoroughly with the towel after washing. 

After labor the responsibility of the nurse begins. 
Before the child is put to the breast she washes the breast 
and particularly the nipples carefully with soap and water, 
and then with 60 to 80 per cent, alcohol. The proper way 
to wash the nipple with alcohol is not to take a piece of wet 
cotton or gauze and rub vigorously. This causes pain and 
may abrade the surface, the very accident that we want 
to avoid. With cotton held below the nipple, alcohol may 
be poured over it from a bottle, or the cotton may be 
saturated and then the alcohol squeezed out, so as to 
thoroughly drench the nipple. Of course no drying is 
necessary, as alcohol evaporates readily. If the child 
should be put to the breast before the alcohol has time to 
evaporate, the nipples may be washed off with sterile or 
boiled water. 



266 



PUERPERIUM 



To protect the nipple from subsequent infection it may 
be washed in the same way with alcohol immediately 
after nursing, when the abrasions are open and before the 
germs carried by the child have had a chance to grow. 
We choose alcohol as a disinfectant because it is fairly 
efficient and entirely safe. Boric acid solution, so much 
used, is such a weak disinfectant that it is but little 
better than sterile water. Efficient disinfectants like car- 
bolic acid or sublimate solution cannot be used because 
they are poisonous to the infant. Very rarely the nurse 
may be directed to use a sublimate solution in case of 
an infected or wounded nipple. In such case she must 
wash off every particle of the poison very conscientiously 
before the baby is allowed to touch the nipple. 

After the nipples are cleaned, they are protected from 
contact with the more or less soiled clothing by covering 
them with sterile gauze. A few layers may be fastened 
to the inside of the gown or placed inside of the supporting 
bandage and changed as often as necessary. Nipple 
protectors made of metal or glass or wood are sometimes 
used for the same purpose. There is the objection to 
these protecting shields that they collect the milk that 
frequently flows during the nursing interval and cause 
the nipples bathed in milk to become soft. 

The danger from dirty hands needs only be mentioned. 
If the nipple must be erected for the child to grasp, the 
nurse may press around its base or else take hold of it 
with gauze, or she may put on gloves. 

The chief danger, as before mentioned, is from the 
face of the child contaminated with pus from sore eyes 
or from boils. To protect the breast from this danger is 
difficult. If the pus comes from sore eyes, they should be 
washed before nursing and then the face thoroughly 
washed. If the baby has boils they should be carefully 
opened, as will be directed in the next chapter, and, if 
necessary, sealed temporarily with collodion. 

In case the glands of Montgomery are infected, each 
separate diseased gland should be opened with a sterile 



LACTATION 



267 



needle after flooding the region with alcohol, the pus 
evacuated, and then the opening closed with collodion. 
A shield may be necessary. 

Nipple shields are very important in cases of depressed, 
deformed, or injured nipples, as well as when the nipples 
are very painful. In the majority of cases there is a day 
or two at least when nursing is very painful on account 
of the nipple. A proper shield will give much relief and 
hence should be a part of the patient's outfit. The best 
shield has the bowl of glass and a rubber nipple attached 
to the bowl. A bone guard keeps the child from getting 
the whole nipple into its mouth. A shield sometimes 
causes pain because of faulty construction. The opening 
may be so small as to constrict the nipple. In a shield 
very commonly used, the bowl has a small opening lead- 
ing to the nipple into which the breast nipple is drawn 
and pinched. Sometimes the flange of the bowl is too 
narrow or attached to the bowl at an improper angle. 
The nurse should study the construction of the shield, 
and if it cause pain she should be able to detect the fault 
and find one that will fit the case, or, if necessary, have 
one made. We should make the shield to fit the patient 
and not expect the patient to fit the shield. 

The rubber nipple is an important part of the shield. 
It must fit the nipple tightly and the opening in its end 
must be large enough, but not too large. The hole can 
be easily enlarged to the required size by passing through 
it a hot needle. 

The care of the shield is a matter of importance. The 
common practice is to let the shield lie around on the bed 
or a table for a few minutes after nursing, and then put 
it into a bowl of boric acid solution that is perhaps quite 
thick with flakes of milk. This illustrates again the 
misplaced confidence in the disinfectant properties of 
boric acid. Immediately after nursing the nipple should 
be taken off from the bowl and both thoroughly washed 
and boiled. It is well, after washing the outside of the 
nipple, to invert it, when the inside can be also well cleaned. 



268 



PUERPERIUM 



After both bowl and nipple are cleaned, they are wrapped 
in a clean napkin or towel ready for use. 

Occasionally the nurse has difficulty in getting the child 
to draw through the shield, but patience and persever- 
ance, sometimes filling the bowl with milk to get the child 
started, will succeed unless the child is feeble. It may be 
necessary to obtain the milk by manipulation or pumping 
and feed with the dropper or spoon. 

Treatment of Breast Infection. — The treatment of a 
slight localized infection of an eroded or fissured nipple 
where there are no general symptoms consists in thoroughly 
cleaning the wound with alcohol and using the nipple 
shield when the child nurses. If the fissure is quite deep 
it might be well to stop nursing for a day. Sometimes 
stick nitrate of silver is applied to the inflamed fissure. 
Balsam of Peru and collodion are also used to close the 
wound. 

In deeper infection of the breast, as known by the 
presence of a chill and fever and other symptoms of infec- 
tion, responsibility for the management of the case rests 
with the physician. In order to prevent the formation 
of an abscess it is a good rule to stop nursing the child 
on the affected side for a few days, support the breast 
with a bandage, and apply an ice-bag over the infected 
area. Properly applied, the ice will give great relief. 
Formerly hot poultices and other hot applications were 
much used. A good fomentation is a cloth moistened with 
a weak antiseptic solution covered with some impermeable 
substance like oil silk or rubber cloth, over which is placed 
a hot-water bag. The redness and tenderness about the 
swollen, infected area will generally disappear after a few 
days unless suppuration takes place. This is known by 
fluctuation or perhaps by aspirating with a hypodermic 
syringe, using a large needle. 

If only one breast is affected the child may nurse 
from the other. If the mother has been around she must 
go back to bed in order that the breast may be kept at 
rest and ice applied. When fever and tenderness have 



LACTATION 



269 



subsided, nursing may be resumed with care, not giving 
up the ice for two or three days. 

When an abscess is formed, it should be opened at 
once, but it is well to continue the ice-bag and the bandage. 
Some kind of local anesthesia is generally used. The 
incision is small and radiating from the nipple, and a very 
small wick drain is used that can be removed in twenty- 
four to forty-eight hours. 



Fig. 95 




Bier suction applied to inflamed breast. 

A large suction cup may be used during the dressing 
to assist the drainage. It also causes a congestion that 
may assist in the healing. It is applied intermittently 
five minutes at a time for two or three times. 

The artificial congestion, or hyperemia, is also used 
before incising to heal a deep infection. This is called 
the Bier treatment. It is more painful than the ice-bag 
and rest treatment and not much used in this country. 

When a large abscess has formed, the evacuation of the 
pus and establishment of drainage constitute a serious 
matter. Sometimes general anesthesia must be employed. 
An irrigator and a large quantity of solution may be 




270 



PUERPERIUM 



required. Drainage tubes or cigarettes and gauze bandages 
must be on hand. In these cases subsequent dressings are 
often needed for many days. 

Galactorrhea. — A deficiency in the secretion of milk 
(agalactia) and the possibility of correcting it by diet have 
been discussed on page 248. The term polygalactia, 
which means excessive secretion of milk, is applied to that 
condition when there is a continual distention of the 
breast, and apparently more milk is produced than is 
needed for the child. It is generally associated with gal- 
actorrhea or an excessive flow of milk. The milk dis- 
charges from the nipple in the intervals between nursing. 
In some cases a pint or more may discharge in the course of 
a day. This is not only uncomfortable to the mother, but 
also a drain on her. Unfortunately but little can be done 
to control the flow. Pads to absorb the milk and com- 
pression bandages are used. 

Hypertrophy of the Axillary Sweat Glands. — Occa- 
sionally a swelling is noticed in the region of the axilla 
on one or both sides. It may be small or it may reach 
the size of the hand. Sometimes several distinct swellings 
are present. If these are carefully examined they will be 
found to lie in the skin and not under the skin. They 
are enlarged sweat glands and not lymphatic glands. At 
times a secretion can be obtained from them which has 
been called a kind of milk, and this has led to the idea 
that these swellings have the structure of milk glands. 
It is true that supernumerary breasts exist and are found 
on various parts of the chest and sometimes in the axillary 
region, but these swellings that we are now considering 
have not the structure of the mammary gland. They 
may appear in the last weeks of pregnancy or more often 
in the first week of the puerperium. They sometimes 
cause a little discomfort which can be relieved by the 
application of an ice-bag or a compress. They disappear 
spontaneously in a few days. 

Care of the Room. — The temperature of the room 
depends somewhat upon the question whether the infant 



LYING-IN ROOM 



271 



is constantly present in the lying-in chamber or not. 
Every lying-in room should contain a thermometer. As 
will be shown in the next chapter, for the first two or three 
weeks it is better for the infant if the temperature of the 
air is not below 75°. If the baby is feeble or troubled 
much with colic, a temperature of 80° is still better; 
hence if the baby is kept in the room with the mother a 
temperature of 75° should be maintained. If the baby has 
a separate room and is only brought to the mother to 
nurse (the best arrangement where it can be carried out), 
the temperature of the lying-in room may be kept a few 
degrees lower if the mother wishes. These remarks 
apply of course to the colder seasons of the year. In 
the summer, when the problem is to keep cool, the proper 
shading of the room, good ventilation, and keeping a 
moist air are the things to be attended to. 

Under any circumstances, proper ventilation is very 
important. This means a free supply of good air without 
the creation of a dangerous draft. Generally we have 
to use the windows for ventilation. At least every two 
to three hours there should be a complete and rapid 
change in the air of the room. The patient should be 
well covered and two or more windows opened as far as 
possible for about five minutes. In this way there is a 
complete renewal of the air without cooling off the walls 
of the room. At other times windows may be slightly 
lowered from the top or raised from the bottom so that 
the air may be kept in good condition. 

The comfort of the patient depends very much upon 
the degree of moisture present. A hydrometer in the 
room is very desirable. If the air is too dry it may be 
easily moistened by throwing a spray of water from a hand 
atomizer, now very commonly found in most households. 

Odors caused by the bowel movements are never to be 
concealed by burning pastilles; they must be removed 
be ventilation. 

Since the nurse is responsible for the care of the room, 
she may be obliged to attend to the cleaning of it herself. 



272 



, PUERPERIUM 



This implies that she understand how to sweep both 
carpets and hardwood floors, and that she knows that 
filling the air of a room with dust which settles back 
on the furniture to be again dusted into the air is not 
cleaning. A good housewife will be very uncomfortable in 
bed if her room becomes untidy and neglected. The more 
refined she is, the more will she hesitate to speak to the 
nurse about a dirty corner or a disorderly dresser or 
neglected, wilted flowers. The condition of a room is, 
moreover, one of the best indices of the breeding and 
training of a nurse. A nurse who neglects her room is 
hardly one to inspire general confidence in other things; 
hence, both the interests of the nurse and the welfare of 
the patient make it desirable that more attention should 
be given to this subject than it ordinarily receives. 

Rest. — To secure the best progress of a patient and 
make of childbed what it should be, a fortnight or a month 
of quiet rest and happiness after the long months of 
pregnancy and the severe labor of delivery, careful 
attention must be given to other details of management. 
The patient should have mental as well as physical rest. 
She remains in bed and careful attention is given to her 
bodily needs. She should also be protected from mental 
annoyances and harmful excitement. 

Of chief importance is the conduct of the nurse. An 
unsympathetic nurse can so disturb the patient that she 
will always look back to her childbed with unhappiness. 
Conscientious performance of duty, unselfish patience, 
and tact are the three requisites in a nurse, and the lack 
of any one is a serious drawback to her usefulness. Many 
a nurse gives too little thought to the last two qualifi- 
cations, thinking more of her own comfort than of the 
patient's feeling. She talks much of the nightly dis- 
turbance of a colicky baby. Lacking in tact, she fails to 
observe the patient's disinclination to hear stories of 
other patients or of the hospital, or the gossip in which 
she may be a proficient entertainer. Some otherwise 
good nurses are impossible because of this lack of tact or 



RULES FOR NURSES 



273 



because of an uncontrolled temper. Few, however, are 
incorrigible, and very many need only a reminder of their 
failings. To these the following suggestions are recom- 
mended : 

Be patient. The more the baby cries and the mother 
worries, the more need of patience. Never allow yourself 
to speak or think of the baby as cross or bad-tempered. 
A baby cries because something is the matter. If you 
cannot find out and correct the cause, bear with it. Never 
call the mother cranky. This word, unfortunately heard 
not infrequently in the hospital, is often used by the nurse 
as an excuse for a retaliatory spirit or one which will 
very quickly engender coolness and a mutually unsym- 
pathetic attitude. 

Avoid gossip about other patients, their families or 
family affairs, or about physicians. However interesting 
such gossip may be, it will not increase the patient's 
respect for you, while it may cause you trouble in ways 
you little imagine. 

Avoid showing anxiety at any emergencies that may 
arise. Keep a sharp watch of the case and report imme- 
diately to the physician anything abnormal, but carry 
what responsibility you have to take quietly, and do not 
needlessly or uselessly shift it on to the patient. 

Protect the patient from household annoyances. 
Members of the family sometimes need to be reminded 
of this rule. If troubles arise in the housekeeping ar- 
rangements, help to smooth over the difficulties and keep 
the patient free from worry. 

You must see that the patient has a time for sleep 
during the day, and you should protect her from disturb- 
ance from every source during this hour. 

In normal cases for the first three or four days of child- 
bed a few short visits from relatives or intimate friends 
may be allowed. Exaggerated strictness in this regard 
is unnecessary. The nurse must only observe that the 
patient is not tired or exhausted by these visits and 
that her rest is in no way disturbed. 
18 



274 



PUERPERIUM 



Many patients wish to be much alone even in their 
waking hours. The nurse should instinctively recognize 
this fact and gratify her patient's unexpressed desires. 

Toilet. — The comfort and welfare of the patient depend 
very much upon the general care given to her toilet. 
It is not necessary to speak of the care of the mouth and 
hair. The care of the genitals and the breast has been 
described before. The rest of the body should receive 
a sponge bath twice a day with water or alcohol. 

Posture. — If the patient wears a proper abdominal 
bandage and a well-fastened napkin, she may with advan- 
tage move around the bed as freely as she likes and lie in 
any position agreeable to her. The possibility of an air 
embolus has caused some physicians to keep their patients 
quiet after labor. If there is any danger from this source 
it is over in a few hours. After the first week it is well for 
the patient to take the knee-chest position for five minutes 
at a time four or five times a day. It helps to relieve pelvic 
congestion and assists involution and tends to prevent 
backward displacement of the uterus. It may be made a 
part of the exercises about to be described. 

If any person, even a healthy man, be put to bed and 
kept at rest in a recumbent position for several days he 
becomes weak from lack of exercise and from disturbed 
circulation, so that if he suddenly attempts to sit up he 
becomes dizzy and faint. This is the condition we fre- 
quently find in women in childbed. There are reasons 
why women should remain in bed as a rule from seven to 
ten days, but the muscular weakness and faintness that 
frequently arise from such a course are evils that should 
be avoided if possible. The chief reason why a woman 
should remain in bed during her puerperium is that she 
may rest and recuperate from the exhaustion of her preg- 
nancy and her labor. The care of the child and the imme- 
diate resumption of her household and social duties would 
be too great a strain on the civilized woman. Even 
among savage or half-civilized races, with the exception 
of a few tribes of North American Indians, there is a 



MASSAGE AND PASSIVE MOVEMENTS 



275 



general observance of a certain period of exclusion from 
association with others, ostensibly perhaps on account of 
uncleanliness, which practically results in a period of rest. 
In spite of the most exact rules regarding a gradual 
progress, permission to get out of bed generally results 
in the resumption of household duties. Moreover, a 
perfect healing of the frequent tears in the uterus, vagina, 
and perineum is favored by the recumbent posture. The 
lochia generally ceases earlier and the involution of the 
genitals progresses more undisturbed; there is less ten- 
dency to a prolapse of the vagina and uterus. Before 
involution of the abdominal walls there is more danger 
of enteroptosis, the prolapse of the abdominal viscera; 
hence a physician feels it a risk to allow a patient to get 
up before involution has progressed fairly well, even at 
the end of the second week. 

Massage and Passive Movements. — To avoid the evils 
that result from the non-use of the muscles, from the 
accumulation of waste in the tissues, etc., massage and 
passive movements and bed exercises are of great value. 
A professional masseuse can be employed with advantage 
after the fourth day, for the nurse who cares well for 
mother and child has scarcely time to give massage. 
Yet very few patients can afford to have a masseuse, and 
the question arises, Is massage of sufficient importance 
to justify the nurse in slighting some other work if neces- 
sary in order to give it. Generally, bed exercises which 
the patient may take without assistance are a good sub- 
stitute for massage. Sometimes when massage is very 
desirable it cannot be given by the nurse because she has 
never been taught the manipulations. 

To those who have not been trained in this important 
art, one may say, as was stated before in speaking of mas- 
sage of the abdomen for the management of constipation 
(see p. 244), that the principles are simple, and applied 
common-sense will soon help one to acquire considerable 
proficiency. 

Suppose a nurse allows thirty minutes for the massage 



276 



PUERPERIUM 



and ten minutes more for movements of the lower extremi- 
ties. With the patient on her face she first rubs the back 
and hips superficially for about two or three minutes and 
then kneads and rubs deeply and strikes for about six 
minutes, leaving one. minute for a rapid rubbing of the 
skin with alcohol. Then ten minutes are given in the same 
manner to the thighs and legs, the patient still remaining 
on the face. Afterward she turns and lies on her back 
and the remaining ten minutes are given to the abdomen 
and front surface of the lower extremities. Then come 
the passive movements, which consist in the flexion of the 
legs on the thighs and the thighs on the body against a 
slight resistance of the nurse, followed by opposed exten- 
sion of thighs and legs. These movements, first of one and 
then the other extremity, or of both together, varied 
with similar movements of the feet, combined with the 
massage, are at least sufficient to prevent stagnation of the 
circulation and weakness of the muscles that have made 
confinement in bed so objectionable. 

Bed Exercises. — For the voluntary exercises, which 
may also begin on the fourth day unless the breasts are 
too uncomfortable, the patient should be flat on the bed, 
with the breast bandage and heavy clothing removed 
and with the windows open. In place of the resistance of 
the nurse the patient makes her own resistance. While 
she is contracting the flexors she holds the extensors 
tense, and vice versa. 

The first movement is a breathing exercise. The 
initial position is with both arms, hands, and fingers 
extended to the utmost, and forming with the body a cross 
and with the lungs full. The extended arms are then 
swung through arcs of 90 degrees and brought together 
above the body, breathing out through this part of the 
movement; then they are slowly swung back to the 
original position during inspiration. The entire move- 
ment requires fifteen to twenty seconds. This movement 
is repeated four to eight times. 

The second movement is combined flexion and extension 



BED EXERCISES 277 

of the parts of the upper extremities. Beginning from 
the initial position the patient flexes in order slowly, and 

Fig. 96 




Bed exercises: First position, full inspiration. 



against her own strong resistance, the fingers, wrists, 
forearms, and finally arms against the chest, breathing 

Fig. 97 




Bed exercises: Second position, expiration. 



out all of the time. Then she extends the parts in the 
reverse order and inspires during the half-movement. 



278 



PUERPERIUM 



The entire movement takes about twenty seconds. This 
she repeats four to eight times according to its effect. 
Ordinarily she would begin with four movements and after 
two or three days increase the number. 

The third movement is extension and flexion of the 
feet. The patient begins with the legs straight, feet 
extended, and toes flexed. Then she flexes the feet and 
extends the toes, and vice versa. About twenty of these 
movements are made in a minute without regard to the 
breathing. 



Fig. 98 




Bed exercises: Autoresisted flexion and extension of upper extremities. 

These three movements take about four or five minutes. 
The patient then rests a minute or two and repeats them. 
The three movements repeated constitute one exercise. 
Three to five exercises are taken each day from the third 
or fourth day to the eighth. Then the fourth movement 
is added. 

The fourth movement is the combined flexion and 
extension of the legs, thighs, and feet. The thighs are 
flexed on the abdomen, the legs on the thighs, and the 
feet on the legs and the toes extended. Then the move- 
ment is reversed. Five to ten movements are made at 
the rate of about five movements per minute. 



BED EXERCISES 



279 



From the tenth to the fourteenth day two more move- 
ments are added. The fifth movement is a flexion of the 
extended lower extremities on the abdomen and a return 
to the initial position. The sixth movement is a flexion 
of the trunk on the thigh. The trunk is raised to a vertical 
posture by contraction of the abdominal muscles and 
without aid of the arms. The legs must remain on the 
bed. Both the fifth and sixth movements are made four 
to eight times at the rate of four times a minute. 



Fig. 99 




Bed exercises: Flexion and extension of legs and thighs. 



Getting Up. — Formerly most physicians kept their 
patients in bed about four weeks after confinement. 
Recently a number of obstetricians have favored letting 
the patient get up on the third or fourth day, sometimes 
on the second day. For the reasons given on page 274 
we favor a longer rest in bed, but recognize that there are 
many circumstances to be considered which determine 
the practice in individual cases. 

A patient who has had a healthy pregnancy and has 
been active up to the last, does not need as long a child- 
bed, other things being equal, as one who comes to con- 



280 



PUERPERIUM 



finement weak and exhausted through chronic illness, like 
heart or lung disease, or through some trouble due to 
pregnancy or from overwork. 

A patient who has had a short and comparatively 
easy labor, and particularly one who has had no hemor- 
rhage, needs a shorter time in bed than one weakened by 
labor. 

Lacerations of considerable extent are a contra-indica- 
tion to early rising. 

Fever in childbed from any source makes a longer 
childbed desirable. 

Persistence of the lochia, and especially the lochia 
rubra, makes necessary a longer retention of the hori- 
zontal position. 

Rapid involution of the uterus is favorable to early 
rising. However, it is not always safe to rely upon the 
passing of the uterus from the abdomen into the pelvis 
as a sure sign of rapid involution. 

If the patient has a nurse-girl to take care of or assist 
in the care of the child, she may get up and dispense with 
the services of the nurse sooner than one who must alone 
take full charge of the baby. 

Finally a doctor's decision concerning the length of 
time in bed must depend upon whether the patient can 
be trusted to follow the directions and not use the per- 
mission to get up for a few minutes to remain out of bed 
for half a day. 

It is a common idea that a patient is likely to suffer 
harm if she walks much or walks up and down stairs 
when she gets out of bed, while it is all right for her to 
sit up for two or three hours. This is an error. In the 
usual sitting posture, enteroptosis, or falling of the ab- 
dominal organs, is favored by the still relaxed abdominal 
walls. On the contrary, if she holds in her abdomen when 
walking this danger is avoided. Moreover, the muscular 
contractions in walking favor the venous and lymph 
circulations. Hence it is better for the patient to walk two 
or three minutes at a time several times a day than to sit 



GETTING VP 



281 



up for twenty or thirty minutes. The rule should be: 
Walking comes before sitting. 

In an average case the patient may get up on the 
seventh day and walk briskly one or two minutes, holding 
in the abdomen as just described. She may do this 
four or five times a day. This may be made a part of the 
regular exercise, being added to the bed exercise. By the 
tenth day she may walk five minutes and then sit for not 
more than five to ten minutes each time she gets up. 
During the third week she may be up half an hour each 
time, going to the table and also using the closet and per- 
haps the tub bath. During this time she may go up and 
down stairs and out of doors. She should not resume her 
household duties if she can help it. After the fourth week 
she is around as usual, but lies down to nurse the baby and 
remains lying about half an hour each time. It is also 
desirable for her to keep up the bed exercises until the 
end of the fourth week. 

If the labor or puerperium has been abnormal so that 
she is not in good condition and her progress is delayed, 
especially if the abdominal walls are very lax and there 
is a considerable separation of the recti muscles, she should 
make extra efforts to strengthen the abdominal wall by 
proper exercise. It may be necessary for her to wear a 
supporting band when she begins to go around. 



CHAPTER VI. 



THE INFANT. 

In this chapter we shall consider the study and care of 
the newborn and young infant only so far as concerns 
the obstetrical nurse. By newborn we mean the child 
which retains any vestiges of its fetal condition. This 
stage generally lasts about two weeks until the navel 
cord is off and the wound healed. For a few weeks more 
the infant is often under the care of the obstetrical nurse. 
We shall notice briefly the more important physiological 
processes and describe the care of the newborn and young 
infant, taking up only the more common affections of the 
first few weeks of life and leaving to books on pediatric 
nursing the more extended study of children's diseases. 

First Care. — The first care of the infant begins with 
the expulsion of the head. As soon as the head is born 
the physician, or the nurse in his absence, should find out 
whether the cord is around the child's neck by passing 
the hand over the back of the head. If a loop of the cord 
is felt around the neck it is pulled over the head, else 
it may interfere with the birth of the body, and on account 
of the stretching of the cord cause harmful traction on 
and premature separation of the placenta. Rarely the 
cord is wound twice around the neck. In this case first 
one loop and then the second is pulled over the head. 

If the cord is not around the neck or as soon as it has 
been attended to the face is at once wiped off with a 
piece of dry gauze or a clean towel or napkin. The out- 
side of the eyes are wiped, but the lids are not opened, 
neither is the mouth wiped out or washed. 



ASPHYXIA NEONATORUM 



283 



Should the birth of the body be delayed on account 
of large shoulders or absence of sufficient pains the head 
may become quite black from congestion. Ordinarily this 
need not alarm the nurse should she happen to be alone 
with the patient, and under no circumstances should she 
attempt to hasten delivery by pulling on the head. If 
there be severe hemorrhage she may help to press out the 
child (see p. 205), but generally there is no need to 
interfere. 

Asphyxia Neonatorum. — As soon as the body is born, 
the first care of the attendant is to see that the child 
breathes. As a rule it gasps almost as soon as the body 
is out of the vaginal canal, soon cries, and within a 
minute or two is breathing regularly. Sometimes it 
makes a few respiratory movements while the body is 
still unborn. If the baby attempts to breathe while the 
head is still inside the vagina it is because of some 
obstruction to the fetal circulation and asphyxia is apt 
to result. 

Should the child be alive and yet not breathe for two 
or three minutes after birth, it is said to be asphyxiated. 
Apnea, which means lack of breathing, is a better term 
than asphyxia, which means lack of pulse, but the latter 
term is in general use. The asphyxia or apparent death 
of the newborn is due to different causes and is of different 
degrees of severity. In any person the act of breathing 
is produced by a stimulation of the respiratory centre 
in the brain by the lack of oxygen or by the presence of 
CO2 in the blood which circulates in the brain. If this 
breathing centre is numbed by poisonous substances in 
the blood it may not respond to stimulation and the 
person is asphyxiated. This nerve centre may also be 
numbed by injury. The fetus in the womb requires 
no air, for the placental blood furnishes oxygen and 
removes the fetal waste. Hence the fetus makes no effort 
to breathe. If the interchange of blood from the placenta 
to the fetus be interfered with in any way the fetus may 
be excited to make breathing movements, or it may be so 



284 



THE INFANT 



gradually poisoned that the respiratory centre is numbed 
without first being sufficiently excited to cause respira- 
tory movements. The fetal circulation may be disturbed 
either by interfering with the cord or the placenta. The 
circulation in the cord may be stopped by pressing upon 
it, as, for example, in cases of prolapse of the cord, when 
it will be compressed between the head and the pelvis 
or by a knot in the cord. The placental circulation may 
be disturbed by a partial separation of the placenta from 
the uterus. This may happen from an injury, such as 
a blow upon the abdomen or from a wrong position of 
the placenta, as in placenta previa. The placenta may 
also be injuriously compressed by the contractions of 
the uterus during labor. If from any of these causes the 
fetus suffers it may become so asphyxiated that it makes 
no effort to breathe and is born in this condition, or it 
may try to breathe before birth, when it will aspirate into 
the mouth and air tubes the water and mucus from the 
genital tract. We may therefore have the child asphyxi- 
ated either with or without mucus in its throat. Still 
another cause may have produced the asphyxiated con- 
dition, namely, injury to the brain either during a hard 
labor, where there is much compression of the head, or 
with forceps used to or resuscitating extract the child. 

Treatment. — Two degrees of asphyxia are generally 
distinguished: asphyxia livida, or congestive asphyxia, 
and asphyxia pallida, or pale asphyxia. In the first case 
it is generally possible to excite respiration by stimulating 
the surface of the body, while in the second case stimula- 
tion may not be effective, and it is necessary to force 
air mechanically into the lungs. Remembering these 
conditions and factors, we adopt the following procedure 
in bringing-to or resuscitating an asphyxiated child : 

Slapping. — First we lift the child from the bed with 
its head down, grasping it with the left hand by the feet, 
holding one leg between the thumb and forefinger and 
the other between the fore and middle fingers. The child 
is held in this position to cause the blood to flow to the 



ASPHYXIA NEONATORUM 



285 



brain and also to empty from the lungs and air tubes any 
liquid that may have been drawn in. Then the child is 
slapped gently on the buttocks with the right hand. 



Fig. 100 




Suspension and slapping of asphyxiated infant. 



Removal of Mucus. — If this does not excite the child 
to breathe it is laid on its back on the bed and the attend- 
ant takes an aspirating catheter and inserts it into the 
throat, holding the tongue forward with the forefinger 
of the left hand. The catheter is often but wrongly called 
a "tracheal" catheter. No attempt should be made to 



286 



THE INFANT 



carry it through the larynx into the trachea. It should 
be always on hand and ready for use. As soon as it is 
inserted the attendant applying the mouth to the outer 
end draws into the tube what mucus and liquid can be 
obtained and then the catheter is withdrawn and the 
contents blown out. It is then reinserted and again used 
as before. When no more fluid is found in the throat the 
child is again raised by the feet as before and another 
effort made to excite respiration by gently slapping the 
buttocks. 

Fig. 101 




Removal of mucus with an aspirating catheter. 



Hot and Cold Bath. — If this last attempt is unsuccessful 
the cord must be at once tied and one more effort made 
to excite the brain centre by another kind of superficial 
stimulation. The body is first held for a few seconds in 



ASPHYXIA NEONATORUM 



287 



a large pan or tub of warm water, temperature 100° F., 
and then placed for an instant in a tub of cold water as 
it comes from the hydrant or cold water from a pitcher 
is poured over the child. Then it is changed back and 
forth from the warm to the cold water a few times until 
the child begins to breathe or there seems to be no longer 
any hope from this method. 

The nurse will see the great importance of being pre- 
pared for these efforts to revive the child. Should she be 
alone with the patient she ought to make all the prepa- 
rations in every case so that she be not taken unawares. 
The baby's bath-tub and a large bowl, or perhaps a wash- 
tub, answer very well. For the cold water the stream from 
the faucet of the bath-tub or the sink may be used. 



Fig. 102 




^ 

Laborde method of artificial respiration. Grasping the tongue with 
small tongue forceps. 

Laborde Method. — Another method of reflex stimulation 
is the intermittent traction on the tongue, which was 
originated and described by Laborde. The tongue is 
grasped with a suitable tongue forceps or with the thumb 
and finger between layers of gauze. It is then pulled out 
carefully as far as possible and held for a second, when it 
is released. These tractions should be made about fifteen 



288 



THE INFANT 



times to a minute, and may be continued for that length of 
time. 

If the methods for exciting respiratory movements 
already described be unsuccessful the nurse should apply 
her ear to the baby's chest and listen carefully to deter- 
mine whether there is any heart pulsation. If any beating 
of the heart is heard, no matter how faint, slow or irregular, 
she should at once take means to get air into the lungs. 
Even when she is doubtful whether the heart beats at 
all or not, she would better use artificial respiration for 
a few minutes. Several methods of filling the lungs with 
air will be described. 



Fig, 103 




Byrd method of artificial respiration. Inspiration. 



Byrd Method. — In the Byrd method the child is held 
so that the right hand supports the upper part of the 



ASPHYXIA NEONATORUM 



289 



trunk, the head resting between the thumb and forefinger, 
while the left hand holds the lower part of the trunk and 
the breech, the left leg resting between the thumb and 
forefinger. If desirable the child may remain in the warm 
bath during the manipulations. By rotating the thumbs 



Fig. 104 



Combined Byrd method of respiration. Expiration. 



outward or the ulnar bodies of the hands upward a dorsal 
flexion of the child is made which tends to expand the 
chest cavity and draw air into the lungs. The reverse 
rotation is then made with the hands, which flexes the 
child and presses the air out of the lungs. These move- 
19 



290 



THE INFANT 



ments are repeated about twelve times a minute until 
the child begins to gasp. As soon as voluntary respiratory 
movements begin the nurse should endeavor to time the 
artificial movements to correspond with the voluntary 
movements. 

Fig. 105 




Combined Byrd and Sylvester method of inducing respiration. 
Inspiration. 



Sylvester Method. — In the Sylvester method the child 
lies on its back on a table with a small blanket under the 
shoulders. The nurse first seizes the arms and draws 
them above the head, causing inspiration. She then 
returns them to the sides of the chest and compresses it, 
causing expiration. These movements are also made 
about twelve times a minute. 

Combined Byrd and Sylvester Methods. — If there be 
two persons to care for the baby the two methods just 



ASPHYXIA NEONATORUM 



291 



described can be combined. The second nurse extends 
the arms of the child while the other makes the first or 
inspiratory movement with the Byrd manipulation. 
Then she brings them to the sides of the chest and helps 
compress it during the expiratory flexion. This can be 
done with the child in the bath. 



Fig. 106 




Combined Byrd and Sylvester method of respiration. Expiration. 



Schultze Method. — The accompanying figures illustrate 
the Schultze swingings, which are made in the following 
way: Standing with her feet apart the nurse holds the 
child with the open hand supporting the back, the index 
fingers in the axillae under the arms, the thumbs over the 
shoulders and in front of the chest. The infant tongue 
forceps, which may be used to keep the tongue forward to 



292 



THE INFANT 



prevent closure of the throat, is caught and held by the 
thumb. Starting from the first position, where the nurse 
bends slightly forward and holds the body hanging down, 
she then straightens her body and swings the child so that 



Fig. 107 




Schultze swinging. Inspiration. 



legs and thighs are flexed on the chest. This movement 
contracts the chest and is the expiratory movement. It 
also favors the brain circulation. Then the child is swung 
back to its first position. This expands the chest and one 
can frequently hear air rush into the lungs. Complete 



ASPH YXIA NEON A TO RUM 



293 



swinging up and down should take six to eight seconds. 
The swinging should be repeated if necessary ten to 
twelve times, when the child should be immersed in a 
warm bath to prevent it from becoming chilled through. 



Fig. 108 




Schultze swinging. Expiration. 



When the method is carried out according to the 
directions given it is very efficient, and by it air can be 
forced into the lungs of a dead child. Of course it is 
very important that no accident happen, for example, 
that the child does not hit a piece of furniture in swinging 



294 



THE INFANT 



and that it is not allowed to fall. The nurse should prac- 
tice with a dead child or, if this is impossible, with a large 
flexible doll until she feels competent. 

Insufflation. — The breathing of air into the baby's 
lungs is done in the following way: The child, laid upon 
its back with the air passages free from mucus, is grasped 
with the right hand around the waist below the chest, 
the thumb pressing firmly over the stomach. Its lower 
jaw is raised with the thumb of the left hand and the 
lips opened with the fingers. Then the nurse applies her 
lips to the baby's mouth and blows slowly and carefully. 
One or two layers of gauze are first laid over the mouth 
to protect the nurse from a possibly diseased child and 
to protect the child from possible infection by the nurse. 
The chest is now grasped with both hands and compressed 
to expel the air. The lungs are filled and emptied in this 
way ten to twelve times or until the child breathes, and 
then it is put back into the warm bath as described 
before. By this method, the filling of the stomach and 
bowels with air is generally avoided. Care must always 
be taken not to blow too hard, for there is danger of 
rupturing the air cells and forcing the air into the tissues 
around the chest and neck. 

The order in which these movements should be em- 
ployed may vary. One may alternate the insufflation 
method or the Laborde method with the Byrd method, 
keeping the child in the warm bath. Generally the 
Schultze swinging is the method of last resort. 

When the child begins to breathe we may desist from 
artificial respiration, but it must be watched carefully 
for some time. Although the immediate danger from 
asphyxia is past when the child has cried vigorously and 
breathes with regularity, yet its future depends upon the 
amount of injury to the brain and upon the after-treat- 
ment. Children rescued from pale asphyxia frequently 
die within forty-eight hours in spite of careful watching. 

Protecting the Child Before Separation from the 
Mother— When the child is born it still remains con- 
nected with the mother by means of the placenta and 



CARE OF EYES 



295 



cord. The pulsations generally continue in the latter five 
or ten minutes. Some think it desirable to delay the 
cutting of the cord until the pulsations cease, because by 
so doing the child receives more blood from the placenta 
than when the cord is severed immediately after 
birth. 

It is therefore important that the child be properly 
protected during the period when it has to lie in the 
mother's bed between her thighs. There is always 
present after birth some fruit-water and frequently blood, 
so that unless the child is properly cared for it will 
become wet and cold even if it does not draw the fluid 
into its lungs. The change in temperature to which the 
tender child is exposed for the first time in its life is per- 
haps 25 to 30 degrees, and sufficient to chill it seriously. 

A large thick or double blanket, two yards square when 
folded, should have been washed and laid aside to receive 
the baby. A clean cotton sheet of the same size is placed 
inside of the blanket. This blanket and sheet should 
have been thoroughly warmed before the baby comes. 
After the patient is delivered the water and blood are 
removed with the obstetrical pad or sheet, a dry one is 
inserted if necessary, and then the child is wrapped in 
the warm blanket. If it is breathing properly and there 
is no hemorrhage or other condition on the mother's 
side calling for immediate separation of the baby it may 
lie as long as necessary. 

First Care of the Eyes. — If the eyes require any treat- 
ment they should be attended to during this period of 
waiting for the cessation of the cord pulsations. Some 
physicians use a boric acid eye-wash, but it probably 
has no value and would better be omitted. If it is certain 
that the mother has neither a fresh nor a latent gonorrhea 
the wiping of the face after the birth of the head is suffi- 
cient. Ordinarily it is safer to use a silver nitrate solution 
in the eyes, and this should be the practice of the nurse 
in the absence of the physician or when he has given no 
direction. This method of preventing gonorrheal sore 
eyes of infants was advocated by Prof. Crede, of Leipzig, 



296 



THE INFANT 



Germany, and therefore is called the Crede treatment, 
or instillation. The solution formerly used had a strength 
of 2 per cent. In this country we generally use a 1 per 
cent, solution. One or two drops are put in each eye. The 
lids must be opened and the solution dropped with an 
eye dropper into the eye. The lids are then wiped off with 
cotton. 



Fig. 109 




Cred6 installation of silver nitrate solution to prevent ophthalmia 
neonatorum. 



Tying of the Cord. — As soon as the pulsation ceases 
the cord is tied and cut. Sterilized tape or silk ligature 
is furnished in the outfit already prepared in an envelope 
(see p. 130). If not prepared a narrow tape or silk or 
linen thread can be sterilized by boiling. The ligature 
must be tied tightly and should not be too fine, else it 
may cut through the soft cord, severing the bloodvessels 
as with a knife, and causing fatal hemorrhage. 

The first ligature is tied one inch from the child so as 
to leave room for another ligature next the body if the 
first should slip or cut through. Then the second ligature 
is placed one to two inches nearer the mother and the 



CONDITION OF NEWBORN 



297 



cord is cut with a pair of clean scissors about half an inch 
from the first ligature. The object of the second ligature 
is to prevent the blood in the cord from soiling the bed 
and, in case of twins, prevent bleeding from the second 
child through a common placenta. Many physicians 
tie the cord at the skin junction and cut it so as to leave 
only a thin button that later retracts and gives no 
trouble in the dressing. On account of the possible danger 
of bleeding the nurse may hesitate to use this method. For 
the further management of the cord and care of the mother 
(see p. 169). 

After the cord is tied and cut the baby is taken away 
to a previously prepared warm bed, there to be left until 
the mother is attended to. It is well to lay the head some- 
what lower than the body to allow mucus or other fluid 
to gravitate from the throat and prevent choking by 
its aspiration. It is not necessary to place the child on 
either side because of any supposed possible influence 
of position in helping the change from fetal to extra- 
uterine circulation. 

The Condition of the Newborn. — The most important 
facts concerning the condition of the fetus at the end 
of gestation have been given in Chapter II. Here we 
must consider the condition of the newborn, especially 
noting how it has been affected by the forces acting on it 
at birth as well as a few of the more common pathological 
conditions not due to labor. 

Mature infants differ much in weight and length on 
account of differences in the size of the parents and other 
causes not always well understood. It may be said, 
however, that a weight of seven pounds and a length of 
twenty inches are about the normal average. The body is 
more or less covered with the vernix caseosa, a creamy 
coating consisting of exfoliated epithelium from the skin 
and the secretion of the sebaceous glands. The lower 
part of the body is frequently stained with meconium 
which is passed shortly after birth and sometimes before 
the child is outside of the genital canal. This meconium 



298 



THE INFANT 



is a dark yellowish-green, tar-like substance that is com- 
posed of exfoliated epithelium of the mucous membrane 
of the intestines and bile salts and also exfoliated epider- 
mis, hair, and other contents of the liquor amnii that have 
been swallowed by the fetus. The amount is generally 
about three ounces, and it is all evacuated in two to four 
days. It is sterile at birth, but in the course of twenty- 
four hours it contains a number of kinds of bacteria, 
among them the colon bacillus, which becomes a per- 
manent resident in the intestinal tract during the life 
of the individual. Rarely a mucous plug, called also the 
meconium plug, closes the rectum and comes away before 
the meconium can escape. 

The urine likewise may be voided soon after birth. This 
urine differs from the urine secreted later in containing a 
considerable quantity of uric acid, which not infrequently 
occurs as a reddish "brick-dust" deposit. This may 
cause pain during its passage through the ureters into 
the bladder or in the urethra when leaving the bladder. 
Also the urine for the first few days contains albumin. 

The respirations vary according to the circumstances 
of birth. The pulse is perhaps a little slower than that 
of the fetus, from 120 to 140 a minute. The tempera- 
ture is the same as the interior of the uterus, that is, 
about 99°. As a rule the eyes are opened within a short 
time after birth. The movements of the eyes are chiefly 
reflex instead of voluntary, and for a few days the move- 
ments of one eye do not necessarily correspond with those 
of the other; hence the mother need not be worried 
because the newborn is cross-eyed. Also the bow-legs 
of a child need cause no worry, because they result from 
the attitude of the fetus in utero. 

The first inquiry of the mother is always to learn if 
the baby is all right. The prevalent belief in maternal 
influence is the cause of anxiety on the part of the mother, 
for nearly every woman during pregnancy sees some 
object or has some impression that she fancies may mark 
her child (see p. 65). The marks and deformities that 



MALFORMATIONS 



299 



we sometimes find are either fetal tumors or they come 
from an error in the development of the fetus because 
of a restricted or an excessive development. The effect 
of too little liquor amnii and the resulting compression 
of the fetus has already been mentioned (p. 66). 

Nevi are marks of various kinds on the skin of various 
appearances. Some are much better supplied with blood 
than others. Most commonly they are merely super- 
ficial or stain-like spots and are frequently seen on the 
eyelids or over the forehead and show more prominently 
when the child cries. This variety usually disappears 
in time without treatment. Others are more markedly 
vascular, sometimes strawberry-like in appearance, and 
may need to be removed by caustics or other treat- 
ment. 

Malformations. — Deformities that result from errors 
in the development of the fetus are called malformations, 
and when the individual is considerably deformed it is 
called a monster. When parts of two individuals are 
joined we have a double monster; otherwise, a single 
monster. An example of restricted development in the 
region of the back is a spina bifida, which is due to the 
fact that the spinal canal that was originally formed 
from a groove has failed to close. Failure in the closure 
of the skull leads to various brain and meningeal tumors 
if the skin or any covering persists. If the covering is 
lacking the rudimentary brain or the base of the skull 
is exposed. Another example of non-union of parts of 
the head is found in cleft palate and hare-lip. A failure 
in the closure of the anterior wall of the body may result 
in extrophy of the bladder, where the inside of the bladder 
is exposed. A failure in the closure of the umbilical ring 
leads to a large umbilical hernia, where some or all of 
the intestines and other abdominal viscera may lie out- 
side of the body. Sometimes this may be cured by opera- 
tion. The imperfect development of the genital or anal 
tract may lead to an imperforate anus, vagina or urethra. 
It is therefore important that this condition should not 



300 



THE INFANT 



be overlooked, for it demands immediate operation to 
relieve the bowels or kidneys. Sometimes one or both 
limbs are absent. A not very uncommon deformity is 
the change in the position of organs, a common example 
of which is the undescended or hidden testicle, which is 
in the abdomen or groin instead of the scrotum. This 
organ originates in the region of the kidney and gradually 
descends through the inguinal canal into the scrotum, 
and stoppage in the descent leads to the abnormality. 
As a case of excessive development we might mention 
polydactylism, or the occurrence of more than the usual 
number of fingers. 

Molding the Head. — The head of the newborn is almost 
always molded more or less as it passes through the pelvis 
of the mother (see p. 120). The molding is rendered possible 
by the way the bones of the skull are loosely joined together 
by the membranous sutures and fontanelles. These sutures 
allow the bones to overlap. One of the parietal bones 
is often pushed under the other, while the occipital bone 
and frontal bones may be pushed under the parietal. 
In the usual presentation, with the occiput anterior, 
the head as it passes through the vulva will be most 
compressed at the circumference that passes under the 
occiput and around the forehead and elongated in the 
direction at right angles to the plane that passes through 
this line. 

Caput Succedaneum. — In addition to the molding of 
the head thus produced there is also a swelling of the 
tissues that cover the foremost part of the head. This 
swelling is often formed while the head is still in the 
uterus, and is called the caput succedaneum (see Fig. 50). 
In other presentations, as in face or breech presentations, 
the shape of the head is very different. The deformity of 
the head generally disappears in two or three days and 
requires no interference. 

Cephalhematoma.— Hemorrhage between the periosteum 
and the skull bones causes a soft tumor limited to the 
region of the bone which it covers. This is called a 



BIRTH INJURIES 301 

cephalhematoma. It lasts much longer than a caput, 
but requires no interference. 



Fig. 110 




Anterior view of cephalhematoma, showing sharply defined border of 
swelling. (Peterson.) 

Birth Injuries. — Injuries at birth are the cause of death 
in over 10 per cent, of the children that die during the first 
week of life. Over 10,000 children are lost every year 
in the United States from this cause. Many of these 
deaths are due to intracranial hemorrhage frequently 
caused by fracture of the skull arising in instrumental 
deliveries. Death may also be due to prolonged labor 
and may have occurred before instrumental interference. 
A much larger number of children are injured but do not die. 
They are a frequent cause of convulsions in the newborn. 

When forceps are used in the delivery of the child the 
marks of the blades are frequently seen on the head. 



302 



THE INFANT 



Sometimes the blades cut through the skin making wounds 
that may require dressing and leave permanent scars. 
A not uncommon result of forceps is a temporary paralysis 
of one side of the face, due to the pressure of the blade 
on the nerve of the face; sometimes the bones are broken. 
Other injuries may be due to the extraction of the child by 
the feet. Fracture of the arms, of the collar bone, of the 
thighs, etc., have occurred. These facts show how impor- 
tant it is that the nurse should examine the baby very care- 
fully and report any seeming abnormality to the physician. 

The Skin. — When the child is born there is a remarkable 
change in its environment. In the womb the skin, as 
also the whole body of the fetus, is protected from irri- 
tation of all kinds. Outside every organ and tissue of 
the body is subjected to new and often harmful influences. 
In particular the skin is exposed to many traumatic and 
other irritations and to infection. No wonder that the 
child soon becomes red all over the body. Ordinarily 
this erythema soon disappears as the protective epithelial 
covering becomes able to withstand the new influences 
affecting it. Frequently, however, more or less eruption 
appears, sometimes vesicular and sometimes pustular. 
This is more common on the neck or face or around the 
genitalia or buttocks, since these regions are the ones most 
exposed to infection. The less the skin is exposed to con- 
tact with dirty hands or clothes the less is the infection. 
The erythema ordinarily needs no treatment except 
cleanliness. A small vesicular eruption may be helped 
with a mild soda bath. Pustules, however, must be care- 
fully treated to prevent extension of the infection to 
other parts of the body, and especially to the breast of 
the nursing mother (see p. 266). They should be opened 
under alcohol with a sterile needle and after evacuation 
of the pus touched with a very small amount of tincture 
of iodine on a swab. 

Sometimes a well-marked eczema develops in the peri- 
neal region, due to the lack of care in cleaning the child 
or to irritating stools. This is called intertrigo (see p. 



BABY'S BATH 



303 



309 for management). An eczema of the face may also 
appear during the first weeks of the child's life while it 
is still under the care of the obstetrical nurse. This may 
be caused by improper feeding which must be corrected. 
Meanwhile a protective soothing ointment is prescribed. 

Jaundice or Icterus. — A certain amount of discoloration 
of the skin is found in a majority of the newborn during 
the first two or three weeks of extra-uterine life. Its 
cause is not known. Perhaps it is due to a number of 
causes, among which are destruction of blood-cells, changes 
in the liver functions, etc. It is of no importance and 
requires no treatment. 

\Yhen the jaundice is due to infection from the navel 
wound it is a sign of a more serious trouble. Hence in 
all cases the condition of the navel should be noted and 
if signs of infection are present they should be reported. 

Catarrhal jaundice from an inflammation of the gall- 
duct may occur and also jaundice from a congenital 
stricture of the duct. These cases of course demand the 
attention of the physician. 

The Bath. — The outfit for the baby's bath consists of 
the tub, bath thermometer, wash cloths, soap, oil, and 
towels. The best kind of tub is that made of enamelware. 
Although the first cost is high it is very durable and will 
last for two or three generations. One great advantage 
is that it can be kept clean. A tub twenty-eight inches 
long will answer for one year, when the child can be bathed 
in a large tub. For those who cannot afford the enamel- 
ware tub a tin tub, sold in all the department stores, will 
answer very well if not allowed to rust. For anyone 
travelling, rubber tubs which can be folded up may be 
used. These are not durable and cannot be well cleaned. 

The common bath thermometer enclosed in a wooden 
frame is cheap and should be in every house. The deter- 
mination of the temperature of the water by the hand, 
which is often insensitive to hot water, is too unreliable 
and has often led to the use of the bath so hot as to seri- 
ously injure the tender skin of the infant. 



304 



THE INFANT 



Squares of gauze, cheese-cloth, or soft Turkish towelling 
are best for wash cloths, and should be prepared before- 
hand. 

The genuine imported Castile soap or a good quality 
of unscented toilet soap should be used. 

Pure sweet or olive oil is used before the first bath to 
remove the vernix caseosa. 



Fig. 110 




Baby's bath.. 



A large soft Turkish towel, at least a yard and a half 
square, should be provided to wrap the baby in as soon 
as it is removed from the bath. Two smaller linen towels 
should be provided, one for the face and one for the better 
drying of the creases between the thighs, etc. Clean 
gauze may be used in place of the latter. 

It is well to give the bath in some other room than the 
lying-in chamber. The temperature of the room where 
the child is bathed should be about 85°, and this heat 



BABY'S BATH 



305 



is enervating to the mother. In most houses the bath- 
room is most convenient. If any difficulty arises in heat- 
ing it sufficiently, filling the large bath-tub with boiling 
water quickly raises the temperature as much as is needed. 
The baby is often harmed by letting it become chilled 
in the first bath. This is one of the reasons why some 
physicians prefer to omit the bath for a few days, simply 
oiling the child and wiping it off. 

Before beginning the nurse should see that everything 
needed for the bath, as well as the clothing and navel 
dressing, are in readiness. The bath-tub should be placed 
on a low stool in the bath-room; the closet seat makes 
a good holder for the tub. The nurse sits in a chair 
beside the tub. Sometimes a kind of platform is made 
to fit over the large bath-tub on which the baby's tub 
can be placed. Another good plan when the room is large 
enough is to use a table for bathing and also for all washing 
of the baby. The bath-tub is placed on the table. The 
nurse stands while bathing the child and then lifts it 
out of the tub into the towel lying at the side of the tub. 
Here it is dried and dressed. Whatever the arrangements, 
it is important that the nurse adopt the best and easiest 
method of bathing and caring for the child, since she is 
an example for the mother, by whom it is very desirable 
that awkward, back-breaking methods be avoided. 

The bath-water should have a temperature of 98° to 
99°, that is, it should be blood-warm. After two to three 
weeks it may be two or three degrees colder. Enough 
water should be used so that the baby's body may be 
completely immersed. 

The face should be washed first and wiped before the 
child is put into the tub; then the body should be well 
soaped, especially the folds in the neck, in the groin, 
between the thighs, in the axillae, etc. The soaping 
should be well done and the wet cake may be rubbed over 
the skin. Before the first bath oil is freely used, beginning 
with the head, to help in the removal of the vernix caseosa, 
after which soap is employed. After the soaping is done, 
20 



306 



THE INF A XT 



the child is put into the water, and rubbed well with a 
wash cloth or the hand. When it is taken out of the bath 
it is wrapped in a towel and well rubbed. All the flexures, 
and especially the genital region, are particularly well 
dried with an extra towel; then it is ready for the navel 
dressing and its clothes. 

If washed and dried as directed there will be no need 
of a powder. As a rule powders lead only to carelessness 
and laziness. Generally the child is left wet and a large 
mass of powder is sprinkled on, when it forms a thick crust. 
If the baby should be very fat and any trace of soreness 
seem to indicate a powder, an unscented borated talcum 
powder would do, but it should be sprinkled on very 
thinly and any excess wiped off. 

When the baby is dressed in a sensible way the bathing 
and dressing should not take over fifteen to twenty 
minutes. The best time for the daily bath is about 
nine or ten o'clock in the forenoon, just before a nursing. 
Since the bath and nursing which follows generally con- 
duces to sleep, it may sometimes be well to give the bath 
in the evening if the baby does not readily go to sleep. 
Occasionally it is better to give two baths a day. Since 
all the clothes worn during the day should be changed at 
night, and since the child should be washed, between 
the thighs at least, at bedtime, and as it will add but 
five or ten minutes' work to give it a bath, both an evening 
and a morning bath may be desirable. In hot weather 
especially the evening bath is very refreshing and almost 
necessary to the comfort of the baby. 

Cleaning of the Perineal Region. — The washing of the 
child after the bowels move is very important, for if it 
is neglected or done in a slovenly way, the baby is apt 
to become sore. Moreover the germs that are in the feces 
may cause an infection of the vulva and vagina which may 
ascend through the urethra into the bladder and even 
into the kidney. For a proper washing are required: 
plenty of water, a piece of rubber cloth over which is 
laid a napkin, a bowl of warm water, soap, absorbent 



CLEANING THE BABY 



307 



cotton or gauze, sponges, a towel, and clean napkins. 
The baby can never be properly washed while held across 
the lap, and the position is back-breaking for the nurse 
or mother. It may be cleaned on the bed or on a table. 
If the bed is used the nurse should sit in a low chair, 
having at her right hand on a table the things needed. 
The child is laid on its back with its head away from the 
nurse. The napkin is removed and, holding up the feet 
with the left hand, the thighs are flexed onto the body 

Fiu. 112 




Cleaning the baby. 



and the rubber cloth is inserted under the hips. Then 
with a cotton sponge, using plenty of water, the buttocks 
and anal region are thorougly cleansed, soap being used 
when necessary. The nurse should never wipe upward 
from the anus toward the vulva. After washing the baby 
is carefully wiped and the clean napkin put on. If a table 
is used (Fig. 112), the nurse places the baby in the middle 
and has the basin of water and sponges and napkins con- 
veniently at her right hand. Instead of a rubber cloth 
to protect the bed and a thick napkin to absorb the water, 



308 



THE INFANT 



some prefer to insert a bed-pan so that there need be no 
restriction in the amount of water used. 

Sometimes the baby has very numerous small passages 
that frequently are quite irritating. These may require 
a washing out of the bowel or some other treatment as 
ordered by the physician. Special attention to cleanli- 
ness is needed and sometimes a protecting salve. Should 
a baby be washed after each passage of urine? This is 
not necessary when it is cleaned as described after the 
bowel movements. If the nurse watch the baby carefully, 
she can generally tell from its actions when it is wet, and 
then she should remove the wet napkin and apply a dry 
one at once. At night the napkin need not be changed 
when the baby is asleep. 

It is a common practice to dry the napkins and use 
them the second or even the third time, because of a 
scarcity of napkins or to economize in washing. At the 
same time the mother has probably provided a large 
wardrobe of fancy lace dresses, any one of which has cost 
more than two dozen napkins, and the washing and iron- 
ing of which will more than offset the washing of the 
napkins. 

Care of the Navel. — After the bath comes the dressing 
of the navel. The cord dries up in a day or two and 
separates in from four to fourteen days, leaving often 
a slight raw surface which covers over with epithelium 
in a few days more. The object of the dressing is to pro- 
tect the navel from injury that might be produced by 
the catching and pulling of the clothes and to prevent 
its infection. Infection of the navel is not uncommon 
and frequently causes fever and other sickness. A baby 
eight days old has been known to die of lockjaw where 
the germs of the disease were found on the navel. This 
infection probably came from some contaminated cloths 
used in dressing the cord. When the baby is born it is 
absolutely sterile. It would be possible to put on an 
aseptic dressing that would keep out all germs until the 
navel wound healed. Such a dressing is, however, compli- 



CARE OF NAVEL 



309 



cated and would involve considerable care and expense. 
It is not necessary, for it is possible to manage the navel 
wound antiseptically so that no harm will result. The 
following method is recommended : 

Remembering that the place where infection occurs 
is where the cord separates from the body, this region 
should be thoroughly washed with alcohol, the only 
efficient and non-poisonous disinfectant. A towel or 
some dry cotton is placed over the pubes to keep from the 
genitals the alcohol which is poured over the navel. A 
little cotton saturated with alcohol may also be wound 
around the piece of the cord and left in place for two or 
three minutes. Then clean absorbent cotton is wound 
around the cord so that the sore is well covered. The 
cord is turned over to the left side and held in place with 
a flannel bandage about four inches wide and twenty-four 
inches long. This dressing is, of course, removed when- 
ever the baby is bathed. If it should stick it will soften 
and come away when the baby is put into the water. 
Some physicians prefer to leave the dressing on the cord 
until the latter falls off, and hence give a sponge bath 
until this occurs. If this practice be followed, it is espe- 
cially necessary to clean the junction between the cord 
and the body. If the cord is cut short (see p. 297), no 
dressing is needed except a little sterile cotton. Alcohol 
is poured into the depression containing the short stump 
of cord after the bath, and at other times if there is any 
redness or odor. 

No powder is necessary on the navel. Boric acid 
and bismuth have very little antiseptic value and gener- 
ally form a crust or scab under which suppuration goes 
on undisturbed. After the cord has come away the wound 
is cleaned and cared for in the same manner until all 
discharge has ceased. It is important not to allow the 
depressed wound to become covered with a scab, under 
which bacteria grow. The bandage is only for the purpose 
of holding on the dressing and is discarded as soon as 
the wound is healed. It is probable that it has no effect 



310 



THE INFANT 



in preventing umbilical hernia and may possibly favor 
its occurrence if it constricts the abdomen. 

Umbilical Hernia. — If the navel opening in the abdomi- 
nal wall does not contract well a protrusion of the omentum 
or bowel may occur constituting an umbilical hernia. 
This is favored by much crying or straining, but it is due 
to a primary or congenital weakness and is not the result 
of any mistake in the dressing of the cord. It will gen- 
erally disappear spontaneously, but if it is troublesome 
a strip of adhesive plaster two inches in width should 



be applied so as to bring the abdominal walls together 
and close the opening. No button or other wedge-like 
body should be used, for it would only tend to keep the 
ring open. The plaster strip must be left in place for 
several weeks and perhaps a fresh strip must be used if 
the first comes off. While this dressing is in use the body 
must be cleaned with a sponge bath. 

Care of Genitalia. — In the female infant the vulva and 
the vagina not infrequently become infected and there 
is vulvovaginitis, characterized by redness, swelling, and 



Fig. 113 




Application of adhesive strap for umbilical hernia. 



CARE OF GENITALS 



311 



more or less purulent discharge. Generally the infecting 
agents are the common pus bacteria or the colon bacillus. 
Sometimes gonorrheal germs are present, coming possibly 
from the contaminated vagina of the mother during the 
birth or more often brought to the genitals by the nurse 
from gonorrheal, contaminated lochia, or from gonorrheal 
ophthalmia. Practically all genital infection of the child 
is due to careless handling, bathing, or cleaning. The 
nature of the infection can be determined with certainty 
only by a bacteriological examination. 

The infection may not be confined to the vulva or lower 
part of the vagina. It sometimes ascends through the 
short urethra into the bladder and up the ureters even to 
the kidneys. This infection may subside after a few days 
or weeks and remain latent for months or years to reap- 
pear later as chronic or intermittent pyelitis or cystitis. 

The prevention is care in cleaning the perineal region 
of the child (see p. 306). If infection has already occurred 
it may be necessary to use argyrol or some other anti- 
septic. 

Menstruation in Infancy. — Occasionally a slight bloody 
discharge is found coming from the vagina. Sometimes 
a red uric acid deposit is mistaken for blood. When the 
discharge really contains blood it may be due to injury 
or it may be allied to a menstruation. It does not reappear 
and needs no treatment except cleanliness. 

Adherent Foreskin. — In the male child the foreskin or 
prepuce is more or less adherent to the glans. Sometimes 
the foreskin is long and extends considerably beyond the 
glans. When the opening is very small we have the con- 
dition called phimosis. Drops of urine may be retained in 
this foreskin canal and eventually cause irritation. Occa- 
sionally a considerable amount of smegma is collected under 
the prepuce just behind the glans, and this may also become 
a source of irritation. 

For the sake of keeping the foreskin and glans clean 
the adhesions between them may be broken down with 
a probe and the foreskin retracted until it is perfectly 



312 



THE IN F ANT 



free from the glans. Then it is again pulled back to its 
proper place. To accomplish this it may be necessary 
to dilate the foreskin. 

The nurse should never undertake to retract the 
foreskin. This is an operation and must be performed 
by the physician. Improper interference may lead to 
injuries and infections. Sometimes when forcible but 
unskilled manipulations are made by the nurse the fore- 
skin is retracted behind the glans and then contracts 
as a tight ring, the glans swells, and it becomes impos- 
sible to replace it. This condition is called paraphimosis. 
The same rule applies to the penis as to the breast. Leave 
it alone. 

If the physician dilates the penis and retracts the fore- 
skin he may expect the nurse to dress the child, that is, 
repeat the manipulations daily. For the first two or three 
days there may be some difficulty, and it is important 
that the nurse very "quickly pull back the foreskin after 
retracting it. An application of sterile vaselin on the 
probe or with cotton aids in the procedure. 

Circumcision. — Sometimes the foreskin is removed by 
circumcision. This operation is also practised as a 
religious rite by some sects and races. The operation 
is made in different ways and the physician will say what 
instruments are needed. The nurse must prepare a table 
in a good light and cover it with a clean sheet. She must 
also furnish a basin with an antiseptic solution and 
sponges, sterile towels, and sterile petrolatum or oil. 
The child is undressed and cleaned and then held by the 
nurse while the physician operates. Often the child is 
given one-half teaspoonful of brandy in sugar-water as 
an anesthetic. 

After the circumcision the nurse must watch the child 
closely for two or three hours for bleeding. 

Undescended Testicles. — The testicles, like the ovaries, 
originate in the abdomen and gradually descend during 
fetal life. They finally pass through the inguinal ring 
and before birth reach the scrotum. Sometimes this 



CARE OF MOUTH 



313 



descent is interfered with and the testicles remain 
in the abdomen or in the inguinal ring. As a rule no 
immediate treatment is instituted, but the condition 
should be noted and perhaps extra care used to avoid 
hurting the testicles lying in the groin. 

The Breasts. — There is a certain amount of swelling, 
glandular development, and functional activity in the 
breasts in nearly all children of both sexes during the 
first two weeks of extra-uterine life. The excretion 
("witches' milk") that can be expressed is similar to the 
colostrum found in the mother's breast during pregnancy 
and immediately after labor (see p. 251). Sometimes the 
swelling is so considerable as to cause anxiety to the mother 
or uninformed nurse and lead to efforts to empty the breast 
by manipulation or to the use of compresses. These 
measures may result in infection and serious injuries, 
and are quite unnecessary. The breast should be left 
alone. At most a protective band could be applied. 

Care of the Mouth. — The common practice of swabbing 
out the mouth once a day with a cloth saturated with 
boric acid solution on the end of the finger is objection- 
able. If the mouth were infected, such a washing could not 
clean it, but, on the contrary, it would probably increase 
the infection by rubbing off the epithelium from the tender 
mucous membrane of the mouth. It is unnecessary, for 
the mouth of a healthy child will clean itself. Should 
the nurse notice at any time particles of regurgitated 
milk they may be removed. 

Thrush. — Thrush is an infection of the mucous mem- 
brane of the mouth and sometimes of the throat with 
a fungus that grows in colonies from the size of the head 
of a pin to a quarter of an inch in diameter. It comes 
from the introduction of germs into the mouth in washing 
it or on the nipple or sugar teat that is given the child 
to pacify it. It is more apt to appear in children whose 
mouths are washed than in those left alone. If the child 
is weakly thrush may be difficult to cure and sometimes 
leads to bowel and intestinal disturbances from which 



314 



THE INFANT 



the child may succumb. The treatment is local and 
general. Before each nursing the child is held in a good 
light and the mouth carefully exposed. The nurse has 
prepared a number of sterile cotton swabs on toothpicks; 
with these wet in sterile water she rubs off the patches. 
No solutions are necessary, only constant attention for 
a few days. Meantime the child must be well nourished 
and the bowels must be kept in good condition. Perhaps 
some laxative will be used to keep the bowels moving well. 

Tongue-tie. — When the frenum, the membranous band 
that attaches the under surface of the tongue to the floor 
of the mouth, is inserted well forward to the tip of the 
tongue it limits its free motion and we have the so-called 
tongue-tie. Very rarely this may interfere with nursing, 
and later in life with good articulation. The physician 
corrects it by cutting the band with scissors. 

Care of the Nose. — Sometimes a little dried mucus may 
collect in the nose. This may be removed carefully with a 
moist sterile swab. Otherwise the nose needs no routine 
attention. 

Not infrequently a mild infection of the nasal passages 
leads to a slight catarrhal discharge. The child has the 
"snuffles." It breathes with some difficulty, especially 
when nursing. The infection may come from contami- 
nation, perhaps with lochial germs, in washing the face or 
by unnecessary swabbing out of the nose. The infecting 
agents are generally the pus germs, sometimes pneumonia 
or grip germs and rarely gonococci. The influenza and 
pneumonia germs may come from a nurse or other person 
who is suffering with a bad "cold." The method of pre- 
vention follows from a consideration of the cause. The 
treatment generally consists in keeping the passages 
lubricated with a drop of liquid petrolatum dropped into 
the nose as necessary. 

Vomiting. — Vomiting in an infant is generally the 
regurgitation of unchanged milk during or shortly after 
nursing. Sometimes the milk may be curdled and there 
are signs of indigestion. This is most frequent in artificial 



DIARRHEA 



315 



feeding. Rarely vomiting may be due to an obstruction 
in the pylorus or to other causes. In the first case the 
regurgitation is generally of little importance. The dura- 
tion of nursing may be lessened and the infant should 
also be kept quiet after nursing. When there are signs 
of indigestion the physician will examine the vomit and 
the milk and may modify the feeding or give some antacid 
or digestant. 

Diarrhea. — As a rule, within twenty-four hours after 
feeding begins, the milk feces appear mixed with the 
meconium, forming the "milk stool." In a short time the 
meconium disappears entirely and the intestinal excre- 
ment is henceforth the feces. It is much thinner than 
meconium, has a bright yellow color, and is fairly homo- 
geneous. Frequently, however, small curd-like masses 
appear and also pieces of mucus. 

Besides the colon bacillus, which lives mostly in the 
colon and rectum, other important germs live in the small 
intestine. In babies fed on breast milk the most common 
bacteria are the Bacillus bifidus and the Bacillus acido- 
philus. In those fed on cows' milk an important germ is 
the Bacterium lactis aerogenus. This germ is a gas 
producer and, like the colon bacillus, probably is a not 
unimportant factor in digestion. 

Ordinarily the newborn has from two to four stools 
a day. Sometimes, however, the stools are more numerous, 
frequently a small passage after each nursing. This is 
not generally of much significance. A small enema or 
a dose of castor oil to clean out the bowel and prevent 
irritation from its contents is sufficient to correct the 
slight trouble. If the stools become quite green on 
passage and contain mucus and are acrid and cause much 
pain and perhaps a little fever, we have a distinct patho- 
logical condition. Some fault in the feeding is suspected, 
especially if there has been any artificial feeding. Harmful 
germs may have got into the intestine and succeeded in 
overcoming the colon or lactic bacteria which help pro- 
tect the body from the pathogenic microorganisms. 



31G 



THE INFANT 



The treatment is generally to stop feeding for a day or 
two, giving only water or barley-water and cleaning out 
the bowel with castor oil or enemas or both. 

Castor oil is often given in teaspoonful doses. Some 
physicians favor giving 10-drop doses frequently repeated. 



Fig. 114 




Giving enema to baby with funnel and tube. Soft-rubber bulb syringe, 
shown on table, may also be used. 

For giving an enema a 3-ounce ear syringe made in one 
piece of soft rubber is satisfactory. A catheter or small 
rectal tube attached to a funnel may also be used. The 
ordinary fountain syringe and the bulb syringe are not 
so good. 

Constipation. — Occasionally a newborn infant will 
have only one stool a day and sometimes none without 
help. This may be due to a deficiency of fat in the food 
or perhaps to a deficiency in the amount of food. Besides 
correcting the cause, if possible, it may be necessary to 
assist the baby to secure at least one bowel movement 



COLIC 



317 



a day. It is well to begin to establish a habit and secure 
a movement before the daily bath. A small salt-solution 
enema may be used or a soap suppository. Frequently 
the introduction of a thermometer into the rectum is 
sufficient to start the movement. 

Colic. — Etymologically this term means an affection 
of the colon. Practically it means an acute paroxysmal 
pain of any kind. Applied to infants it means either 
intestinal colic or else that due to the passage of urinary 
calculi through ureters or urethra. This can sometimes 
be diagnosed by finding that the pain occurs when the 
red uric acid deposit passes from the bladder. Intestinal 
colic is due to irregular, cramp-like contractions of the 
bowel. 

Very few babies escape colic entirely. Sometimes it 
is very persistent and makes the most important com- 
plication of a case. In intestinal colic there is generally 
some fault in digestion, but it is often impossible to deter- 
mine definitely the causes. If the baby gains in weight 
in spite of its crying, the mother may be assured that there 
is no danger. 

Intestinal pain due to inflammation of the bowel can 
generally be distinguished from colic by the character of 
the pain and the difference in the tenderness on pressure. 

The treatment of colic should be to remove the cause. 
If the cause cannot be discovered it is necessary to give 
the child relief at least temporarily. The best way, as a 
rule, is to give a salt-solution enema. Sometimes a dose 
of castor oil gives relief. Both of these means probably 
act by producing a general movement of the intestines 
and thus relieving the local excessive action. A mild 
carminative such as oil or essence of peppermint or 
wintergreen will also act in somewhat the same way. 
The baby should be kept warm, especially its feet. Some- 
times a general warm bath will be necessary. 

Urinary colic is frequently accompanied by symptoms 
of intoxication. There is often fever and respiratory 
disturbances. It is probably an important factor in many 



318 



THE INFANT 



of the fevers of the newborn that are sometimes, without 
very good reason, called inanition fevers. It is best 
treated by giving large quantities of water by mouth 
and rectum. 

Care of the Ears. — The external ears should be kept 
clean like all parts of the skin. There is very rarely 
occasion to interfere with the auditory canal. 

Care of the Eyes. — Healthy eyes need no washing. 
There may be a slight irritation of the eyes for two or 
three days after birth from the Crede instillation (see 
p. 295). This will generally disappear of itself. If there 
is a slight watery discharge the eyes may be washed four 
or five times a "day with a boric acid solution. The common 
practice of washing the eyes every morning is unnecessary 
and would better be omitted. There is no occasion to 
fear the mild light of a room. Probably an intense light, 
as the direct sunlight shining into the baby's face, would 
be unpleasant, as such a light is to any person. Light is 
not the cause of sore eyes, which are the result of an 
infection. 

Ophthalmia Neonatorum. — Gonorrheal infection of the 
eyes of the newborn is the common cause of a serious 
disease that generally appears two or three days after 
birth, and unless well treated leads to blindness. This 
is the cause of half the blindness in the world. The germs 
of gonorrhea exist generally in a latent state in the vulva 
and get on to the face of the child during its passage 
out of the vagina. The germs get into the eyes when they 
are opened after birth. They soon set up a violent gonor- 
rhea of the conjunctiva, with the formation of much pus. 
Frequently the lids stick together and pus accumulates 
in large quantities between them and the eyeballs. Soon 
the inflammation extends from the conjunctiva to the 
cornea, and here produces one or more thickened, opaque 
patches. When these patches are over the pupil the 
sight is lost. Sometimes there is deep ulceration, which 
may lead to perforation of the eyeball. 

Every case of inflammation of the eyes must be 



CARE OF EYES 



319 



reported at once to the attending physician, who will 
immediately institute treatment. A microscopic exami- 
nation of a smear of the pus will determine the nature of 
the infection. If gonorrheal, frequently two or three 
drops of a 1 per cent, nitrate of silver solution will be 
dropped into the eye as in the prophylactic Crede instil- 
lation (see p. 295). Sometimes a stronger solution is 
used with the dropper or on a swab. The eyes are then 
washed frequently, every half-hour to one hour, day and 



Fig. 115 




Ophthalmia neonatorum. 

night, with boric acid or normal salt solution. This may 
be used with an eye dropper or, better, with an irrigator. 
Between the washings ice compresses may be applied. 
Some physicians prefer hot compresses. Occasionally argy- 
rol or protargol or some other albuminate of silver is used 
instead of nitrate of silver or in conjunction with it. 

Non-gonorrheal infection of the eyes may result from 
contamination with colon bacilli or pneumonia germs 
or other germs found on the hands of the nurse or on the 
cloths used to wash or wipe the face of the child. This 



320 



THE INFANT 



form of infection is not generally serious and is easily 
controlled by washing the eyes before each nursing with 
boric acid or salt solution. 

Subconjunctival Hemorrhage. — A bright-red spot cover- 
ing one-fourth or more of the front of the eye is due to 
a hemorrhage beneath the conjunctiva, caused perhaps by 
rupture of a minute vessel during birth. It causes no 
trouble and will disappear by absorption in two or three 
weeks. 

Dress. — The child should be dressed so as to protect 
it from loss of heat and the changes of temperature which 
occur even in the summer season. Decorating a baby or 
making it look pretty, unless it can be done without inter- 
fering with its health and comfort, should not enter into 
consideration. The method of dressing babies that is still 
not uncommon in this country, by which they are enclosed 
in three or four long, heavy, white skirts, while over the 
neck and arms is only a thin dress covered with lace, is 
directly opposed to the proper principles of dress. The 
mother often gives much time and labor to preparing a 
wardrobe that is quite unpractical because she has never 
had her attention called to the importance of warm, loose, 
comfortable clothing. Let her understand why all parts 
of the body should be protected, and why the baby should 
be dressed for comfort and not for show, and she will not 
only acquiesce in a common-sense outfit, but become 
enthusiastic over it. 

Every object changes its temperature, that is, loses 
its heat or cold in direct ratio to the extent of its surface 
and not to its weight. For example, two blocks of ice 
that weigh ten pounds each will melt quicker than one 
that weighs twenty pounds. A baby that weighs seven 
pounds will lose in a given time much more than one- 
twentieth as much heat as an adult that weighs twenty 
times as much, or 140 pounds. Moreover, the cooling off 
of a living body depends also upon the nature of the 
external layer. If the skin is lined with a good layer of 
fat, the body cools slowly. Newborn babies have but 



DRESS 



321 



little fat, and hence lose heat very rapidly. To conserve 
the vital energy of the baby it is therefore necessary to 
protect it well, not only the lower part of the body, but 
also the upper extremities. 

For the first months of its life the baby should sleep 
most of the time and realize practically no difference 
between day and night. Its exhibition to relatives and 
strangers distracts its sleep and exposes it to changes in 
temperature as well as to dangers of infection. Let it 
lie undisturbed, both day and night, in clean, warm, 
loose garments, and it will thrive best. 

As a soft, warm, absorbent material both for diapers 
and shirts, the Arnold knit goods, or garments of like 
pattern, can be recommended. The diapers, especially, 
have been so extensively advertised and sold that they 
hardly need any description. For its softness and absorb- 
ent properties it has perhaps advantages over any woven 
material. The shaping of the diaper to fit the body by 
taking a gore in the center and folding across the gore 
is especially to be recommended, for it prevents the 
diaper from slipping and makes it fuller in the seat where 
the chief amount of material is needed. A peculiar 
soft, warm, cotton cloth now on the market, made 
especially for diapers, is cheaper than the Arnold knit 
goods, and is preferable to linen or cotton flannel. The 
small squares to be laid in the seat of the large diapers 
is a good addition for young babies. Unless the napkins 
are changed quite often the contents soak through and 
the skirt becomes wet. To prevent this at night, an extra 
napkin may be fastened around the body, but not bound 
around the thighs. 

There are times when the rubber diaper might be used, 
for example, at a christening; but ordinarily it is ob- 
jectional and should not be worn. 

The short shirts are best made of cotton or cotton and 
wool, or silk and wool, so that they do not shrink too 
much. The stretcher is convenient to use in drying the 
garment. 

21 



322 



THE INFANT 



If the baby is born in the warm season, stockings are 
not necessary, but in winter, unless the house is kept at 
an even temperature, they are often valuable. They are 
fastened to the diaper by safety pins. 



Fig. 116 




Sack gown for newborn infant. 



In summer a long skirt of single thickness may be all 
the baby needs in the daytime, while at night the double 
garment is put on. In winter it is well to use both the 
single and the double garment. In this mode of dressing, 
the arms are protected as well as the body. An additional 
sleeveless skirt is quite unnecessary. Pinning blankets 
which hamper the exercise of the legs are not only un- 
necessary but undesirable. 

In some hospitals a much simpler outfit is in use, and 



DRESS 



323 



there is no valid reason why it should not be used in 
private houses. Such an outfit consists of a diaper and 
a sack-like garment without sleeves, that ties around 
the neck and extends below the feet. It may have a 
shirring string in the bottom so that the baby may be 
entirely enclosed in the bag. Such a garment has the 
advantage of keeping the hands and feet enclosed so 
that they cannot become cold and the baby cannot get 
its hands into its mouth or scratch itself. Its simplicity 
and cheapness together with its other advantages makes 
its more general use advisable. 

The bibs, to be worn continuously if the child regurgi- 
tates much, or otherwise only at feeding time, should be 
absorbent and from nine to ten inches long, large enough 
to be of value. Fine Turkish towelling is a good material 
to make them of. 

The house jacket is a very important garment. While 
the lower part of the body is enclosed in blankets, the 
arms and chest may be free and exposed. A short house 
jacket should be adapted to the temperature of the room. 
If the room is quite cool or if the child is exposed to drafts, 
a thick knitted jacket or a sweater is greatly to be recom- 
mended. 

The outside jacket, the hood or cap, and the cloak, as 
well as the shoulder blankets to wrap the child in when 
being carried about the room or from place to place, need 
no special description. 

All clothing should be changed night and morning. 
The shirts worn one day may be aired and worn again 
unless soiled. The nurse is responsible for the care of 
the clothes. If she does not wash them herself she must 
see that they are washed properly. The Arnold goods, 
at least the diapers, require no ironing. Napkins soiled 
with feces must be washed out in cold water, rinsed, 
and then well boiled and rinsed again. When soiled with 
urine, they should be rinsed well with, hot water. 

Sleep. — Since the baby sleeps most of the time when 
it is not eating, its bed is an important matter. It should 



324 



THE INFANT 



never sleep in the same bed with the mother, because 
the air is not so good, there is danger of the mother's 
lying on it, and it is apt to disturb the mother. If it is 
possible it should sleep in another room which can be 
warmed and ventilated to suit the baby. Frequently 
a temporary bed, suitable for five or six months, is made 
out of a large clothes basket or a basket made for the 
purpose is procured. A hood at the head is unnecessary 
and objectionable, as it interferes with good ventilation. 
This basket-bed may be placed on a low table or perhaps 
on a large chair. If it is in the mother's room it should 
stand in a protected part. At the bottom a small hair 
mattress is laid and covered with a piece of rubber cloth 
over which is spread a thick flannellette blanket or a 
comforter, and then a warm flannel blanket, which also 
lines the sides of the basket. The baby is then wrapped 
in a thick flannel blanket, or, in warm weather, perhaps 
in a shoulder blanket. In the warm season of the year 
or in a room well ventilated without drafts the baby gets 
better air and seems to enjoy itself more when it lies on 
the bed in daytime. Sometimes a child's crib is provided, 
before the baby comes. A rocking crib or cradle is 
unnecessary and objectionable. The ordinary crib with 
low sides answers very well for the baby, but is objection- 
able as soon as the baby is large enough to climb up, for 
then it is likely to fall head first out of the bed. For a 
child's bed, suitable also for older children, that is, those 
a year or two old, a crib with some kind of a safety device 
that has sides high enough to prevent a child falling out, 
when it is old enough to stand up, is to be recommended. 
The open construction of such a bed also allows perfect 
circulation of air. 

A baby needs no pillow. It may lie on the back, on 
either side or on its face. The latter position is often indi- 
cated when it has colic. 

All bed-clothing should be well aired every morning 
while the baby is bathing or nursing. 



FEEDING 



325 



Feeding— In Chapter V, p. 252, it was stated that the 
baby should be given the breast secretion from the 
beginning, because the colostrum is nourishing and a 
proper food for the newborn, and because nursing is advan- 
tageous to the mother. Until the milk secretion is well 
established the baby may nurse, when the mother's 
condition does not contra-indicate, every three or four 
hours if the baby is awake. Since the colostrum does 
not generally furnish liquid enough it is necessary to 
add water. For this reason the nurse should give the baby 
as much pure water as it will take, generally two or three 
teaspoonfuls at a time every two hours. Occasionally 
when it is necessary to get a large quantity of water into 
the system, as in anuria or urinary colic, sugar- water, 
one or two teaspoonfuls to the pint, may be given. Man- 
aged in this way, the baby will keep in good condition 
for the first two or three days of its life before lactation 
begins, and will not lose more than 6 to 12 ounces in 
weight. 

If the breast is not very well developed and the baby 
does not take hold of the nipple well, or if the condition of 
the mother indicates a need for considerable rest, it is 
not good to annoy her at first too much with nursing the 
child. At no time should it be at the breast longer than 
twenty minutes. 

After the milk has come the regular routine for the 
feeding of the baby must be determined and followed out. 
It is best that the baby should be fed with some regularity, 
both for the convenience of the mother and the good of 
the child. Although little lambs or calves may run to 
the mother every few moments it does not follow that 
it is a good plan for children of civilized parents to adopt 
the same rule. Those mothers who nurse their babies 
every time they cry, thinking they are hungry, may 
become martyrs to the practice. On the other hand, an 
unvarying insistence upon a two-hour or a three-hour 
rule may also become a tyranny, and may be quite 
unnecessary. 



326 



THE INFANT 



It is important to study the child's needs. While 
some children ought to be fed every two hours, others, 
because they have larger stomachs or obtain more milk, 
go very well three or four hours between nursings. To 
make a two-hour child go three or four hours without 
nursing will torture and harm it, while to wake a four- 
hour baby and insist upon its nursing every two hours 
will tire out the mother and nurse. 

The best index of the sufficient feeding of a child is 
his growth. If he gains properly from day to day or from 
week to week, that is from one-half ounce to two ounces 
a day, or from four to ten ounces a week, he gets enough 
to eat, although there may be some fault in the com- 
position of his food that causes colic. On the other hand, 
although a baby may be very good and quiet, yet if he 
loses in weight or stands still he is not getting sufficient 
food. Hence it is important that the baby should be 
weighed as accurately as possible from time to time. 

A scale that will weigh to ounces at least is very desir- 
able. A lever balance with separate weights or with a 
sliding weight is most satisfactory. If no such scales 
are accessible, however, a spring balance is better than 
nothing. 

A child should always be weighed under the same con- 
ditions as respects his mealtimes. The best way is to 
weigh him naked in the morning immediately after his 
bath. The weight should always be recorded. 

If question arises as to the sufficiency or amount of 
mother's milk it may be answered by weighing the child 
before and after nursing, provided sufficiently delicate 
scales are used. It is not necessary to take into account 
the clothes of the child if they remain the same in both 
weighings. 

A normal child, to make a satisfactory gain in weight, 
will generally need from one-eighth to one-tenth of its 
weight of mother's milk every 24 hours. A prema- 
ture child will require proportionally more (see p. 338). 
Ordinarily one may determine, in the course of four or 



FEEDING 



327 



five days, the proper routine for the nursing of the baby. 
If the child is very weak or premature it may be neces- 
sary to nurse him oftener than once in two hours. In the 
case of a fairly well-developed child this is the shortest 
period. About half of all babies may be fed every two 



Fig. 117 




Baby scale. 



hours -during the daytime, that is, from seven to eight 
o'clock in the morning until eight to ten o'clock at night. 
During the night, of course, the child is allowed to sleep 
all that it will. During the daytime it should be awakened 
at the nursing time, when the proper interval has been 
established. In the rest of the cases it may be found 



328 



THE INFANT 



desirable to let the baby go two and a half or three or 
sometimes even four hours between nursings. 

Ordinarily the baby gets sufficient milk from one breast, 
and it is convenient for the mother to nurse the breasts 
alternately. If, however, the child does not get sufficient 
from one breast it is best to give both at one time. This 
is a good practice, as it stimulates the breasts, and thus 
increases the amount of milk secreted by them. It should 
not remain at the breast longer than fifteen minutes or 
at the most twenty minutes. If it holds the nipple too 
long in the mouth the nipple becomes macerated and more 
easily wounded. Besides, the mother is exhausted. 

Occasionally a child is unable to obtain sufficient milk 
from the breast, either because the milk does not flow 
well through partly obstructed or very small milk ducts, 
or the nipples are depressed or small or hard to grasp, or 
because the baby is too weak to make any nursing efforts. 
This trouble generally confronts us during the first four 
or five days of the child's life. If the child can be nourished 
for a few days it will become strong enough to get milk 
from the breast, if the mother has a sufficient secretion 
for it. In these cases the nurse must get the milk from 
the breast and feed it to the child. At first she may be 
able to obtain only a teaspoonful at a time; after a day 
or two she can generally get three or four teaspoonfuls. 
The milk can be gotten by carefully milking the breast 
with the hands. Sometimes a breast-pump may work 
better, but, as a rule, a skilful nurse can do as well with 
the hand as with the pump and cause less pain. When 
possible, if the mother is not diseased, a more vigorous 
healthy baby may be applied to stimulate and develop 
the breasts. The milk can be collected in a small cup, 
warmed by setting the cup into a large vessel of hot water, 
and fed to the baby with a teaspoon. If only a teaspoonful 
of milk can be obtained at a time it may be necessary 
to feed the child each hour. Sometimes the physician 
may order a little stimulant to be added to the milk, a 
drop or two of brandy. In these cases it is desirable to 



FEEDING 



329 



give the baby as much sweetened water as it will take, 
for sugar and water are important elements of the child's 
food. While the child is thus fed it should be put to the 
breast every three or four hours in order to try and dis- 
cover if it will not nurse. After it begins to draw from 
the breast it should still be fed on the mother's milk with 
the spoon until the mother and nurse are convinced that 
it gets sufficient by nursing. 

When no milk can be obtained from the breast for 
several days it may be necessary to feed the child some- 
thing more than sweetened water. Sometimes because 
of sore breasts or on account of sickness of the mother 
artificial feeding temporarily or permanently must be 
resorted to. The physician will of course prescribe the 
food and the method of preparing and giving it. 

In order to understand why cows' milk, which would 
seem to be the most natural food for children, may not be 
a good food for young babies, we must, for a moment, 
study its composition and compare it with woman's milk. 
As is well known, milk is a complex food containing, besides 
water and certain mineral salts, sugar, {. e., milk-sugar; 
fat, i. e., butter and proteid substances, one of which, 
casein, is the important part of cheese. Milk is normally 
curdled in the stomach juice. The kind of curd that is 
formed by milk depends upon the amount and kind of 
proteid that is present in it. Cows' milk differs from 
woman's milk in having a larger proportion of casein. 
Moreover the casein of cows' milk forms a denser, tougher 
curd than does that of woman's milk. Hence it follows 
that if unchanged cows' milk be given to babies, tough 
indigestible curds may be formed which can cause 
stomach and bowel disturbances. 

To change the cows' milk so that it will answer better 
for an infant's food, water is added to dilute the proteid. 
This dilution, however, makes the milk poor, as it dimin- 
ishes also the proportion of sugar and fat. To counteract 
this objection fat, in the shape of cream, and sugar are 
added to the diluted milk. What amounts to the same 



330 



THE INFANT 



thing for small babies as diluting milk and adding cream 
is diluting cream. 

In order to see more clearly the changes that take place 
by this process of modifying milk, let us look at the com- 
position of woman's milk and cow's milk and cream. 

Woman's milk contains in 100 parts: 

Proteids 1 to 2 parts 

Sugar, about 6 parts 

Fat, about 3 parts 

Cow's milk contains in 100 parts : 

Proteids 3 to 4 parts 

Fat, about 4 parts 

Sugar, about 4 parts 

A good cream will contain in 100 parts: 

Proteids 3 to 4 parts 

Fat 16 parts 

Sugar 4 parts 

Now it will be seen that when we dilute this cream 
with three times its bulk of water the mixture will con- 
tain in 100 parts: 

Proteids, about 1 part 

Fat 4 parts 

Sugar 1 part 

If to such a mixture milk-sugar or dextrose be added to 
make it as sweet as ordinary milk we will have a food 
very nearly approaching the composition of mother's 
milk. This is a good substitute for breast milk for young 
infants. 

It is, of course, important that the cream used in 
making this modification should have a definite compo- 
sition. 

Such precautions are taken, in the production and care 
of certified milk and cream, that it reaches the consumer 
very little contaminated and can be given to the child 
without sterilizing. 



FEEDING 



331 



The ordinary market milk is not so carefully handled 
and is generally considerably contaminated when it is 
delivered, so that it should be sterilized always before it 
is given to infants. Boiling is the simplest way of 
sterilizing. The mixture is put into an enamelware basin 
and carefully boiled for three to five minutes on a stove 
or over a gas flame. Of course care must be taken not 
to burn the milk. The water that is lost by evaporation 



Fig. 118 




Siphoning lower milk to leave top milk in bottle. 



should be replaced or, better, a sufficient extra amount 
of water should be added beforehand to leave the proper 
quantity after evaporation. The milk may also be put 
into nursing bottles and sterilized by steam in an Arnold 
or a similar steam sterilizer. Careful boiling, however, 
answers every purpose and for the small amount generally 
needed temporarily with infants it is perhaps preferable. 

Another method of modifying the chemical composition 
of milk is to use a certain amount of the top milk of a 



332 



THE INFANT 



bottle obtained by siphoning off the lower portion of the 
milk. The upper eight ounces of a pint of milk will con- 
tain nearly all the fat and hence would have about the 
following composition : proteids, 4 per cent. ; fat, 7 to 8 per 
cent.; sugar, 4 per cent. This diluted with a pint of 
water would have 1.33 per cent, proteids and 2.33 to 2.66 
per cent. fat. This sweetened properly by adding a well- 
rounded tablespoonful of cane-sugar gives the proper 
proportion of carbohydrates and is a very good mixture 
for supplementary feeding of a newborn child. 

The quantity that should be given to a child depends 
upon its age and condition and upon the frequency of 
feeding. During the first two weeks \ to 1 ounce may 
be given every two hours, while during the next two 
weeks 1 to 2\ ounces may be given every two or three 
hours. The milk may be given with a spoon or with a 
nursing bottle. If the artificial feeding is temporary 
it is better to use a spoon. Even when a child is fed con- 
tinuously there are some advantages in feeding with a 
spoon. The chief advantage is the absence of danger 
of contamination of the nursing bottle. The bother of 
cleaning properly the bottle and nipple is also avoided. 
If a bottle is used the Hygeia bottle can be recommended 
(see Fig. 119) as one that can be thoroughly and easily 
cleaned. If the ordinary nursing bottle is used it must be 
cleaned with a bottle brush and boiled after each feeding. 
The care of the nipple is the same as the care of the 
breast shield (see p. 267). 

If for any reason the physician prefers to use some 
other kind of food than modified milk he will prescribe 
the method of its preparation and the quantity to be 
used, or the nurse will rely upon the directions which 
accompany the packages. The other substitutes for 
mother's milk, like condensed milk or the various infant 
foods, are not so extensively used nowadays as they 
were before the methods of sterilization and modification 
made cows' milk available. Some of the foods are often 
used, however, in the modification of cows' milk either 




Showing comparative sizes of necks of bottles shown in Fig. 119. 



334 



THE INFANT 



in place of sugar to help sweeten it or to improve its 
digestibility. 

Premature Children. — The death of three-eighths (37.5 
per cent.) of all children that die during the first month of 
life is attributable to prematurity; 15 per cent, more die 
because of congenital debility, which is no doubt assigned 
as the cause of death in many premature children. From 
these two causes about 70,000 children die every year. 
This bald fact shows the very great importance of this 
subject. 

Definition of Prematurity. — Because of the great diffi- 
culty of determining the exact duration of life in the uterus 
we may say that a child is premature if it weighs at birth 
less than 5| pounds and is less than 48 cm. or 19 inches 
long. 

Dangers to which Premature Children are Exposed. — 

The chief dangers to which the premature infant is exposed 
are chilling and starving. Unless great care is taken 
immediately after birth to keep the baby warm, its tem- 
perature will fall in one-half hour to 93° or under. Unless 
the child is quickly warmed it will be seriously injured. 
A temperature of 90° is apt to prove fatal. This rapid 
cooling is due largely to the fact that the surface of the 
body is relatively much greater in proportion to the 
weight than in adults or large children, and hence the 
radiation of heat is much faster. Also the absence of a 
protective layer of fat in the skin favors a dispersion of 
heat. Moreover the nerve centres which control the 
heat production and loss are apt to be unstable. 

To prevent the chilling immediately after birth the 
child must be kept well covered until separated from the 
mother and then put at once into an incubator or a very 
warm room. If it should become cold it must be put into 
a warm bath of a temperature of 102° to 105° and its 
rectal temperature raised to normal. 

Home or Incubator Station. — If the child is born at home 
and can receive there proper nursing and incubation 
arrangements should be made at once for its future care 



INCUBATION 



335 



if this has not been attended to beforehand. When the 
home surroundings are such as to make the proper care 
doubtful the child and if possible the mother should be 
sent to an incubator station. Such a station should be 
in connection with a maternity hospital or a maternity 



Fig. 121 




Incubator ambulance open, showing electric light, thermometer, infant's 
basket with eiderdown flannel mattress and coverlet. (De Lee.) 



ward of a general hospital, so that the proper food, 
mother's milk, may be secured in case the mother is dead 
or her milk fails or if for any reason she cannot accompany 
her child to the station. For the transportation of 
premature infants to the station De Lee's portable incu- 
bator is very desirable. 



336 



THE INFANT 



Warm Room. — To keep the child warm it must stay 
either in a warm room or in an incubator. If a small 
room is available that can be kept at a temperature of 
about 85°, with moist fresh air nothing better can be 
asked. As such an arrangement is rarely possible we 
must generally rely upon an incubator. 



Fig. 122 




Diagram of incubator. 



Incubator. — An incubator for children is simply a box 
or small chamber in which the child lies surrounded by 
a continually changing current of fresh, warm, moist air. 
Elaborate electrically heated incubators may be desir- 
able in an incubator station. A simple and good kind, 
especially for private houses or small hospitals, is repre- 
sented in Fig. 122. The box, 17 x 19 x 22 inches, has 
in the bottom a large tank capable of holding eight ^ 



INCUBATION 



337 



quarts of hot water. This tank is connected by a tube 
with a small filling reservoir on the outside of the' box and 
emptied through a spout closed with a stop-cock which 
comes from the lower part of the tank. Underneath the 
tank is a shallow air space into which air enters from the 
outside through holes in the end of the box. The current 
of air passes under the tank, around its end, over the tank 
and under the shelf on which the baby lies, then around 
the shelf over the baby and out of the hole in the cover. 
A small revolving windmill may be inserted into this 
opening to serve as an indicator of the pressure and 
strength of the air current, but is not necessary. A basin 
attached to the side of the box, holds a wet sponge which 
moistens the air. A thermometer on the shelf beside the 
baby indicates the temperature of the interior. A glass 
door is in the top of the incubator. The air admitted to 
the incubator may be taken from the room or by means 
of a tube from the outside of the house. As the ventilation 
or the velocity of the air current will depend upon the 
difference in the temperature of the air before admission 
and that of the incubator it is well that the room be not 
too warm or that the air be supplied from the outside of 
the house. 

The temperature of the incubator is kept constant 
by withdrawing two to four quarts of water from the 
tank every two to four hours and replacing it with boiling 
water. The temperature of the room and of the admitted 
air determine the quantity of boiling water needed and 
the frequency of the change. 

The temperature of the inside depends upon the needs 
of the child. A very frail and small child weighing less 
than four pounds may require at first a temperature of 
90°. As it grows the temperature may be gradually 
reduced. A child weighing four to five pounds may 
start with an incubator temperature of 87°. It should 
keep a normal rectal temperature without sweating. 
Gradually the temperature of the incubator may be 
reduced to 80°. By this time the child is left out of the 
22 



338 



THE INFANT 



box a considerable part of the daytime and returned to 
it at night. 

When a child is vigorous and develops rapidly it may 
be necessary to keep it in the incubator only a few days, 
while a puny child may require it two or three months. 

It is frequently necessary or desirable to remove the 
child from the incubator to feed it. The room tem- 
perature should not be below 70° for feeding or below 80° 
for cleaning and dressing, and it should be wrapped in 
warm blankets as much as possible while outside. The 
breathing of colder air for 5 or 10 minutes may act as 
a tonic, while a long, thorough cooling would be fatal. 

The incubator must be kept clean, else it may become 
a source of infection. It should always be thoroughly 
disinfected before receiving a new patient. If in use for 
some time it should be thoroughly cleaned every three 
to four days. 

Feeding. — The second danger to which the premature 
infant is especially exposed is starvation. It needs rela- 
tively a large amount of food while its digestive system 
is not very well developed. If it gets too little food it 
starves; if it gets too much or improper food, digestive 
disturbances arise. Woman's milk is almost absolutely 
essential. If it cannot be obtained from the mother 
it should be procured from some other nursing woman. 
If necessary such milk can be collected in small bottles, 
kept cool, and transported like cows' milk. Feeding should 
begin at birth and the amount given increased as rapidly 
as possible until the normal amount for the child is reached. 
As a general rule a premature child requires per day about 
one sixth of its weight of good average milk to supply 
its needs and make the proper gain in weight. It probably 
will be necessary to begin with two or three ounces a day 
and increase to the normal quantity in the course of a 
week. The number of feedings per day will depend upon 
the quantity that can be given at a time. Sometimes the 
child can retain only \ to 1 dram, and then it should 
be fed each hour, day and night. Later, as it can take 



INCUBATION 



339 



Fig. 123 



a larger quantity at a time, the number of feedings a day 
is diminished. 

As the premature infant cannot ordinarily nurse and 
because nursing, even if possible, might be undesirable on 
account of the danger of exposure, it is best to feed the 
child with a dropper or with a feeder 
such as represented in Fig. 123. Occa- 
sionally a small catheter introduced into 
the stomach through the nose has been 
used as a stomach tube for gavage, but 
the patient use of the dropper or feeder 
is preferable. When the child is able 
to nurse it should be weighed on an 
accurate scale before and after nursing 
to determine the amount obtained so 
that a deficiency can be made up by 
feeding. After feeding the child should 
be carefully watched in the incubator 
for some minutes on account of the 
danger of regurgitation which might 
cause choking. 

Oxygen for Cyanosis. — During the first 
two or three days of its life the pre- 
mature child is in danger of asphyxia 
due often to atelectasis or imperfect 
dilatation of the lungs and manifested 
by cyanosis. This is best treated by 
the administration of oxygen. When 
the child is in the incubator the tube 
from the oxygen tank may be intro- 
duced into one of the air-holes and, if 
necessary, one or more of the other 
holes closed. The color of the baby's 
face is the index of the cyanosis and determines the 
amount of oxygen needed. 

Dressing and Bathing. — In the incubator the child needs 
but little clothing, a diaper and a bag gown (see p. 322). 
It should lie on a thick layer of absorbent cotton. It can 



Breck's feeding 
tube for premature 
infants. (Koplik.) 



340 



THE INFANT 



generally be removed from the incubator for cleaning and 
a daily warm bath can be given provided the temperature 
of the room can be brought to 90°. Otherwise it is 
probably better to oil the baby in place of a full bath. 

During the first days of its life the temperature of the 
child may fluctuate rapidly. In this case the room in 
which the child is cared for and the bath should be kept 
in constant readiness. If the child's temperature falls 
much below normal it should be put into a warm bath 
of about 103° until the temperature rises to normal. If 
the temperature of the child is 103° or more it should be 
put and kept in a cooling bath of about 96° until the fever 
is controlled. 

Subsequent History of Premature Children. — Data show 
that the chance of life of the premature child is equal to 
that of the full-term child if the former is cared for properly 
and not discharged until it is as large as a mature infant 
and receives thereafter reasonable care. Its future pros- 
pects for a healthy and well-developed physical and 
mental organism are equal to those of a child carried to 
term. 

Incubator for Other Debilitated Conditions. — Children 
injured during birth and those born partially asphyxiated 
are often in a precarious condition for some days and 
can be treated with advantage in an incubator and along 
the lines laid down for the management of premature 
children. Atelectasis, bronchitis, and acute lung infections 
are also cases for incubator care. 



INDEX. 



A 

Abdomen, pendulous, 102 

striae of, 68 
Abdominal binder, 228 

distention, 68 

examination, 146 
Abortion, 86 

causes of, 87 

complete, 87 

criminal, 87, 195 

definition of, 86 

for hyperemesis, 76 

incomplete, 87 

induction of, 194 

inevitable, 88 

prevention of, 87, 103 

symptoms of, 88, 103 

therapeutic, 194 

threatened, 87 

treatment .of, 88 

tubal, 89 
Abscess of breast, 268 

pelvic, 234 
Absolute indication for c. s., 211 
Accouchement, 105 

force 199 
Acid, boric, 266, 295, 318 

carbolic, 95, 133, 141, 266 
Acini of the breast, 53 
Adherent foreskin, 311 

placenta, 178, 191 
After-birth, 61 
After-pains, 112 
Agalactia, 270 
Air embolus, 274 
Albuminuria in pregancy, 78 
Alcohol, 129, 133 
Allantois, 62 

Ambulance, incubator, 335 
Ammonia water, 74 



Amnion, 62 
Amniotic fluid, 62 
Analgesia in labor, 162 
Anesthesia in labor, 162 
Antiseptics, 132 
Anuria of infants, 325 
Anus, 38 

Apnea neonatorum, 283 
Areola of breast, 70 
Artificial respiration, 284 
Asphyxia neonatorum, 283 

bath for, 286 

Byrd method for, 288 

combined Byrd and Sylves- 
ter method for, 290 

insufflation for, 294 

Laborde method for, 287 

livida, 284 

pallida, 284 

Schultze method for, 291 

slapping for, 284 

Sylvester method for, 290 
Aspirating catheter, 285 

needle, 268 
Atelectasis, 339 
Atonic hemorrhage, 173, 180 
Atony of uterus, 173 
Attitude of fetus, 113 
Auscultation of the abdomen, 151 
Auvard's cranioclast, 220 
Axillary glands, 270 
Axis of pelvis, 34 
traction forceps, 210 



B 

Baby. See Infants and Newborn. 
Bachelle's hebosteotomy needle, 
201 

Bacillus acidopholus, 315 



Note. — Since the meaning of practically all the words used in this 
book can be determined from the text and context, a glossary is omitted 
in the belief that the index freely and properly used will supply its place. 



342 



INDEX 



Bacillus bifidus, 315 

lactis aerogenus, 315 
Bag of waters, 109 
Bandage, abdominal, 228 

for breast, 254 

for leg, 85, 86 

in pregnancy, 101 
Bartholin's glands, 38 
Basins, 128, 143 
Basiotribe, 220 
Bath, antepartum, 135 

for asphyxia neonatorum, 286 

baby's, 303 

for incubator child, 339 

shower, 135 

tub, 135 
Bathing in pregnancy, 99 
Bed for baby, 324 

exercises in puerperium, 276 

for labor, 136 

in puerperium, 228 

sheets, 130 
Bier's suction of the breast , 2(39 
Binder. See Bandage. 
Birth injuries, 301 
Bladder, 50 

care of, in labor, 160 
in puerperium, 240 
Blanket, baby's, 323 
Blastula, 58 

Bleeding. See Hemorrhage. 

Blisters of nipple, 264 

Blood in embryo, 59 

Blood-pressure, 82 

Bony pelvis, 32 

Boric acid, 266, 295, 318 

Bossi dilator, 200 

Bottle, nursing, 333 

Bow legs of newborn, 298 

Bowel, inflammation of, 317 

Braun hook, 220 

Braxton Hicks' version, 202 

Breast, 52, 251 

abscess of, 269 

anatomy of, 53 

areola of, 70 

bandage of, 254 

Bier suction of, 269 

caked, 252 

care of, in lactation, 265 

in pregnancy, 104 
development of, 53, 70 



Breast, distention of, 252 
function of, 53 
ice-bags for, 258 
infection of, 262 
massage of, 259 
of newborn, 313 
pumping of, 253 
secretion of, 70 
shield, 267 
striae of, 70 

Breathing, artificial. See As- 
phyxia. 

Breck's feeding tube, 339 

Breech presentation, 115, 202, 
205, 207 

Brick-dust urine, 298, 317 

Brim of pelvis, 33 

Broad ligament, 43 

Brow presentation, 115 

Byrd method of artificial respira- 
tion, 288 

C 

Caked breast, 252 
Canal, obstetrical, 33 
Cancer of the cervix, 96 
Caput succedaneum, 120, 300 
Carbolic acid, 95, 133, 141, 266 
Card record, 25 
Caries, dental, 77 
Carunculae myrtiformes, 38 
Casebook, objection to, 25 
Casein, 329 

Catheter, aspirating, 285 

bladder, 160, 242 

tracheal, 285 
Catheterization during labor, 
160 

puerperium, 242 
Cephalhematoma, 300 
Cephalic presentation, 115 

version, 202 
Cephalotribe, 220 
Cervix, cancer of, 96 
dilatation of, 199 
effacement of, 109 
Cesarean section, 211 
conservative, 216 
extraperitoneal, 216 
postmortem, 217 
vaginal, 217 



INDEX 



343 



Child. See also Infants and Nc 
born, 
viable, 86 
Childbed, 226 
( Jhill, 235 

Chloral in labor, 162 
Chloroform, 163 
Chorion, 61, 63 

origin of, 61 

villi of, 61 
Cilia of Fallopian tubes, 63 
Circulation, in embryo, 59 

in emesis of pregnancy, 72 
Circumcision, 312 
Cleaning of baby, 306 

of external genitals, 141 
Cleft palate, 299 
Cleidotomy scissors, 220 
Climacteric, 46 
Clitoris, 37 

prepuce of, 37, 38 
Clothing. See Dress. 
Coccyx, 32 
Colds, 19 
Colic, 317 
Collodion, 202, 267 
Colon bacillus, 315 

location of, 244 
Colostrum, 70, 251, 313 
Combined digital version, 202 

manual version, 202 
Complete abortion, 87 
Conception, 56 
Conduct of nurse, 27 
Confinement, 105 

date of, 67 
Conservative cesarean section, 

216 

Constipation in infants, 316 

in pregnancy, 76 

in puerperium, 243 
Contracted pelvis, 34, 188 
Contractions of uterus, 106 
Convulsions, eclamptic, 79, 84 

in newborn, 301 

puerperal, 79 

uremic, 78 
Cord, knot in, 284 

ligation of, 169 

prolapse of, 190 

short, 189 

tying of, 296 



r - Corpus luteum, 49 
of uterus, 41 
Corsets in pregnancy, 10C 
Coryza in nurse, 19 
Cows' milk, 329 
Cracked nipples, 263 
Cranioclasis, 221 
Cranioclast, 220 
Craniotomy, 219 
Crede expression of placenta, 179 

instillation of eyes, 295 
Criminal abortion, 87, 195 
Cross-presentation, 146, 190 
Cry, first, 283 
Curettement, 195 
Cyanosis, oxygen for 339 
Cystitis in puerperium, 242 



D 

Date of confinement, 67 
Decapitation, 221 
Decidua, 63 

reflexa, 64 
Deformed nipples, 263 

pelvis, 34, 188 
De Lee's portable incubator, 335 
Delivery of body, 168 
Dental caries, 77 
Descent, 116 
Diaper, 321 

Diarrhea in infants, 315 
Diet in eclamptogenic toxemia of 
pregnancy, 83 

in lactation, 248 

in pregnancy, 98 

in puerperium, 246 

in vomiting of pregnancy, 73, 74 
Dilatation of cervix, 199 
Disinfection of genitalia, 140 

of hands, 132 
Displacements of uterus, 45 
Distention of breast, 252 
Doederlein's hebosteotomy nee- 
dle, 201 
Dorsal flexion, 203 
Douche bag, 145 

intra-uterine, 224 

pan, 142 

for postpartum hemorrhage, 181 
vaginal, 142, 181, 224 



344 



INDEX 



Drainage pad, 139 
Dress during labor, 136 

for incubator, 339 

of infant, 320 

in pregnancy, 100 
Dublin expression of placenta, 

179 

Duncan's method of expulsion of 

placenta, 125 
Duration of labor, 105 

of pregnancy, 67 

of puerperium, 226 
Dystocia, 105, 187 

fetal, 189 

from abnormal forces, 188 

passages, 188 
from abnormalities of pas- 
senger, 189 
from accidents, 189 
from lacerations, 191 
from prolapse of cord, 190 
from rupture of uterus, 191 
from short cord, 189 
from tumors, 189 
Dysuria, 240 



E 

Ears, care of, 318 
Eclampsia, 79 

treatment of, 84 
Eclamptogenic toxemia of preg- 
nancy, 79 
diet in, 83 
nature of, 79 
sweats in, 83 
symptoms of, 79 
treatment of, 83 
Eczema of infant, 302 
Edema, general, 85 

of legs, 85 
Edgar method of dilating c 

200 
Egg, 54 

development of, 54 
migration of, 63 
nidation of, 63 
structure of, 54 
Effacement of cervix, 109 
Embolism, pulmonary, 274 
Embryo, beginning of, 58 



Embryology, 54 
Embryotomy, 219 
Emesis, causes of, 73 

gravidarum, 71 

management of, 73 
Enema, 75, 134, 245 

nutritive, 75 
Engagement of nurse, 30 
English forceps lock, 209 
Enteroptosis, 275, 280 
Ergot, 183 

Eruptions of newborn, 302 
Erythema neonatorum, 302 
Ether, 163 
Eutocia, 105 

Examination, abdominal, 146 

internal, 156 

of patient, 145 

vaginal, 156 
Exercise in pregnancy, 103 

in puerperium, 276 
Exit of body, 124 

of head, 121 
Expression of fetus, 205 

of head, 206 
Expulsion of placenta, 125 
Extension of head, 124 
External genital organs, 36, 37 

cleaning of, 141 
External os, 43 

version, 202 
Extraction, 207 
Extra-uterine pregnancy, 88 
symptoms of, 89 
treatment of, 89 
Eyes, care of, 318 

Crede instillation of, 295 

subconjunctival hemorrhage of, 
320 

F 



ix, Faoe presentation, 115 
Facial paralysis, 302 
Fallopian tubes, 47 
functions of, 47 
structure of, 47 
Fecal contamination in labor, 165 

impaction, 245 
Feces of infant, 306 
Feeding of infant, 325 
of premature child, 338 



INDEX 



345 



Female pronucleus, 55 
Fertilization, 56 
Fetal appendages, 61 

heart beats, rapidity of, 154 
tones, 150 

tumors, 189 
Fetus, beginning of, 61 

movements of, 68 

relation to mother, 65 
Fever, inanition, 318 

milk, 236, 253 

puerperal, 232 
First cry, 283 

stage of labor, 107 
Fissure of nipple, 263 
Flat pelvis, 34 
Flexion, 116, 203 
Follicle, Graafian, 48 
Foot presentation, 115 
Forceps, 208 
Forces of labor, 106 
Formation of bag of waters, 109 
Foreskin, adherent, 311 
Fore water, 109 
Fornix of vagina, 39 
Fourchette, 36 
Fractures at birth, 302 
French forceps, 209 
Frenum, 314 
Frequent micturition, 85 
Fruit water, 207 
Fundus of uterus. 42 
Fungi in stomach, 76 
Funnel pelvis, 35 



G 

Galactagogue, 249 
Galactorrhea, 270 
Galbiati knife, 201 
Generally contracted pelvis, 35 
Genitalia, care of, 310 

disinfection of, 140 
Genital wound infection, 232 
Gestation. See Pregnancy. 
Gigli saw, 201 
Glands, Bartholin's, 38 

of clitoris, 38 

Montgomery's, 54, 70, 262, 266 
Glans, adhesion of prepuce to, 
311 



Gloves, 131 

Gonorrheal infection in puer- 
pcrium, 233 
of urinary organs, 311 
ophthalmia, 318 
vulvitis, 311 
Graafian follicle, 48 
Growth of infant, 326 



H 

Hair, care of, in labor, 136 
Hands, cleaning of, 132 
Hare-lip, 299 

Harris method of dilating cervix, 
200 

Head, exit of, 121 
Headache in toxemia, 78 
Hebosteotomy, 201 
Hemorrhage, atonic, 173 

from deficient coagulation of 
blood, 176 

from inversion of uterus, 176 

from partial detachment of 
placenta, 175 

intracranial, 301 

postpartum, 172 

prevention of, 176 

in puerperium, 227 

subconjunctival, 320 

traumatic, 175 
Hernia, umbilical, 299, 310 
High forceps, 210 
Hofmeier expression, 205 
Home care of premature infant, 

334 

Hook, Braun, 220 

in forceps handle, 20S 
Hot douche, 181 
Hydatid mole, 96 
Hydrocephalus, 189 
Hymen, 38 

Hyperemesis gravidarum, 71 
causes of, 73 

induction of abortion for, 73 

management of, 73 
Hypodermoclysis, 185, 225 
Hypertrophy of axillary sweat 

glands, 270 
Hysterectomy, 216 



340 



INDEX 



I 

Ice-bag for breast, 258 
Icterus of child, 303 
Ilium, 32 

Imperforate anus, 299 

urethra, 299 

vagina, 299 
Impregnation, 56 
Inanition fever, 318 
Incisions of cervix, 199 
Incomplete abortion, 87 
Incubation, 334 
Incubator, 336 

station, 334 
Induction of abortion, 194 

of labor, 196 

indications for, 196 
methods of, 197 
preparation for, 197 
Inevitable abortion, 88 
Infancy, menstruation in, 311 
Infants, 282. See Newborn. 
Infection of breast, 262 

of genital wound, 232 
Infectious disease in nurse, 19 
Influenza in nurse, 19 
Injuries of birth, 301 
Inlet forceps, 210 

of pelvis, 33 
Innominate bone, 32 
Insanity, puerperal, 239 
Inspection, 146 

of genital region, 155 
Instruments for cesarean section, 
213, 214 

for circumcision, 211 

for dilating cervix, 198 

for embryotomy, 219, 220 

for extraperitoneal cesarean 
section, 217 

forceps, 209 

for hebosteotomy, 201, 202 
for induction of abortion, 195, 
196 

for intra-uterine douche, 224 
for metreurysis, 198 
for Porro-cesarean section, 216 
for postmortem cesarean sec- 
tion, 217 
for repair operation, 222 
for tamponade, 225 



Instruments for symphysiotomy, 
201 

for vaginal cesarean section, 

218, 219 
for version, 203 

Insufflation for asphyxia neona- 
torum, 294 

Interlocking twins, 189 

Intermittent contractions of 
uterus, 106 

Internal genitalia, 38 
os, 43 

Intertrigo of infant, 302 
Intestine, 51 

Intra-uterine douche, 224 
Inversion of uterus, 176 
Inverted nipple, 265 
Involution, 226 
Ischium, 32 
Ischuria, 160 

J 

Jacket for baby, 323 
Jaundice of child, 303 



K 

Kelly drainage pad, 139 
Kidney of pregnancy, 77 
Knee-chest posture, 190 
Knot in cord, 284 
Kristeller expression, 205 



L 

Labia majora, 36 

minora, 36 
Labor, 105 

abdominal examination in, 146 

abnormal, 105, 187 

accidents of, 190 

analgesia in, 162 

anesthesia in, 162 

anesthetics in, 162 

artificial, 105 

auscultation in, 151 

bag of waters in, 109 

bath in, 135 

bed for, 136 



INDEX 



347 



Labor, bladder in, care of, 160 
catheterization in, 160 
causes of, 105 
chloroform in, 163 
cleaning in, 140 
complications of, 187 
contractions of, 106 
Crede expression in, 179 
definition of, 105 
delayed, 105 
delivery of body in, 124 

of shoulders in, 125 
descent of fetus in, 116 
dilation of os in, 107 
disinfection of genitals in, 140 
distention of perineum in, 123 
douche during, 181 
dress in, 136 
duration of, 105 
effacement of cervix in, 109 
enema during, 134 
ergot during, 183 
ether in, 163 
examination in, 145 
exit of body in, 124 

of head in, 121 
expression of placenta in, 178 
expulsion of placenta in, 125 
extension of head in, 121 
external examination in, 146 
first stage of, 107 
flexion of fetus in, 1 16 
forces of, 106 
head delivery in, 124 

rotation in, 121 
hemorrhage in, 172 
hot douche in, 181 
hypodermoclysis in, 185 
induction of, 196 
inspection of genital region in, 

155 

internal examination in, 156 
inversion of uterus in, 176 
involuntary forces in, 106 
laceration of perineum in, 191 
ligation of cord in, 169 
management of, 127 

of third stage, 170 
manual removal of placenta in, 

179 

mechanism of, 113 
missed, 105 



ibor, molding of head in, 120 
moral support in, 161 
morphin in, 162 
normal, 105 
nourishment in, 161 
outfit of nurse for, 128 

of patient for, 128 
pads for, 139, 142 
painless, 106 
pains of, 106 
palpation in, 146 

of perineum in, 155 
perineal laceration in, 191 
pituitary extract in, 183 
position of fetus in, 115 
posture of fetus in, 113 

of patient in, 168 
precipitate, 105 
premature, 105 

preparation of nurse for, 130 

of patient for, 134 
presentation of child in, 115 
prolonged, 105 
pulling in, 165 
rapid, 105 
retarded, 105 
room, 143 

rubber gloves in, 131 
rupture of membranes in, 111 

of uterus in, 191 
scopolamin in, 162 
second stage of, 111 
shaving in, 140 
show in, 109 
slow, 105 
solutions for, 142 
spontaneous, 105 
stages of, 107 
station of child in, 115 
support of back in, 164 

perineum in, 165 
at term, 105 
third stage of, 112, 170 
translation of fetus in, 116 
twilight sleep in, 162 
use of closet during, 135 
uterine contractions in, 106 
vaginal douches in, 142, 181 

examination in, 156 
Walcher position in, 206 
Laborde method of artificial 
respiration, 287 



348 



INDEX 



Laceration of perineum, 191 

of vagina, 191 

of vulva, 191 
Lactation, 251 
Lactiferous ducts, 53 
Laxatives, 77 
Leggings, 130 
Legholder, 133, 194 
Ligaments, broad, 43 

round, 42, 44 

uterosacral, 44 
Ligation of cord, 169 
Linea alba, 68 

nigra, 68 
Liquor amnii, 62 
Lithotomy position, 194 
Liver in pregnancy, 78 
Lochia, 227 
Locked twins, 189 
Lockjaw in newborn, 308 

in puerpera, 239 
Lower uterine segment, 109 
Luteum cells, 49 
Lying in, 105 

room, 143 
Lymphangitis, 234 

M 

Male pronucleus, 55 
Malformations of newborn, 299 
Mammary abscess, 268 

gland, 52 
Management of labor, 127 

of pregnancy, 98 
Mania, puerperal, 239 
Manual dilatation of cervix, 199 

extraction, 207 

removal of placenta, 179 

version, 202 
Marginal placenta previa, 90 
Massage of breast, 259 

of colon, 244 

of stomach, 250 

for postpartum hemorrhage, 180 

in puerperium, 275 
Mastitis, 262 
Maternal impressions, 65 
Meat diet in toxemia of preg- 
nancy, 83 
Mechanism of labor, 113 
abnormal, 190 



Meconium, 297 
Membranes, 61 

examination of, 171 

retention of, 171 
Menopause, 46 
Menstruation, 46, 47 

beginning of, 46 

ending of, 47 

in infancy, 311 
Metreurynter, 197 
Metreurysis, 197 
Micturition difficult, 240 
Milk leg, 234 

stool, 315 

witch's, 313 
Milne Murray forceps, 209 
Miscarriage, 86 
Missed labor, 105 
Modified milk, 330 
Molding of head, 300 
Mole, hydatid, 96 
Monsters, 299 
Mons veneris, 36 
Montgomery's gland, 54, 70, 

262, 266 
Morning sickness, 71 
Morula, 58 
Mother marks, 65 
Mouth, care of, 313 
Movements of fetus, 68 
Mulberry stage, 58 
Multiple pregnancy, 189 
Mutilating operations, 219 



N 

Naegele forceps, 209 

pelvis, 35 
Nail brush, 128, 132 
Nausea and vomiting of preg- 
nancy, 71 
due to toxemia, 78 
Navel, care of, 308 

infection of, 303, 30S 
Needle, Bachelle's, 201 

Doederlein's, 201 
Nephritis of pregnancy, 77 
Neugebauer speculum, 225 
Newborn, apnea of, 283 

artificial feeding of, 328 
respiration of, 284 



INDEX 



349 



Newborn, asphyxia of, 283 
bath of, 303 
bed of, 324 
bowel of, 298 
breast of, 313 

care of eyes of, 282, 295, 318 

circumcision of, 312 

cleaning of, 306 

clothing of, 320 

colic of, 317 

condition of, 297 

constipation of, 316 

convulsions of, 301 

cry of, 283 

cyanosis of, 339 

definition of, 282 

diarrhea of, 315 

dress of, 320 

ears of, 318 

eczema of, 302 

eyes of, 282, 295, 298, 318 

feces of, 299 

feeding of, 325 

first care of, 282 

fractures in, 302 

genitalia of, care of, 310 

growth of, 326 

head of, 300 

hemorrhage from cord of, 296 

hernia of, 299, 310 

hygiene of, 339 

icterus of, 303 

inanition fever in, 318 

influenza of, 314 

injuries of, 301 

intertrigo of, 302 

jaundice of, 303 

malformations of, 299 

marks of, 298 

meconium of, 297 

menstruation of, 311 

milk in breast of, 313 

mouth of, 313 

navel of, 308 

nevi of, 299 

nose of, 314 

nursing of, 325 

ophthalmia of, 318 

outfit of, 321 

pulse of, 298 

pustules of, 302 

respiral ion of, 298 



Newborn, resuscitation of, 284 
skin of, 297, 302 
sleep of, 321, 323 
stools of, 297, 315 
temperature of, 298 
tetanus of, 308 
tongue-tie of, 314 
thrush of, 313 
training of, 29 
umbilical cord of, 294, 296 
urine of, 298 
vernix caseosa of, 297 
vomiting of, 314 
weight of, 297 
Nipple, 54 
injury of, 263 
shield, 267 
Nose, care of, 314 

gonorrhea of, 314 
Nourishment in labor, 161 
Nurse as an example, 30 
as a teacher, 30 
duties of, to doctor, 22 
be loyal, 26 
keep records, 24 
report mistakes, 23 
to patient, 27 
to self, 18 

to avoid bad breath, 18 
gossiping, 28 
infectious diseases, 19 
perfumes, 21 
perspiration odors, 21 
to care for bowels, 20 
for clothing, 21 
for diet, 19, 20 
for exercise, 22 
for hands, 21 
for health, 18 
for lunch, 19 
for night-clothing, 22 
for skin, 21 
for sleep, 22 
for stomach, 20 
for teeth, 20 
engagement of, 30 
outfit of, 128 

preparation of, for care of labor, 
130 

Nursing bottles, 333 

private, or in hospital, 17 
Nympha?, 36 



350 



INDEX 



O 

Obstetrical operations, 191 

(See also Table of contents.) 
Occiput, 115, 119 

posterior position, 205 
Operating room, 192 
Operations, obstetrical, 191 
complications of, 192 
preparation for, 192 
Ophthalmia neonatorum, 318 
Os uteri, 43 
Outfit of nurse, 128 

of patient, 128 
Outlet of pelvis, 34 
Ovary, 48, 54 
Ovulation, 49 
Ovum, 54 

development of, 54 

structure of, 54 
Oxygen for cyanosis, 339 



P 

Pad, obstetrical, 139 

vaginal, 142 
Pains, after, 112 

after-birth, 112 

bearing-down, 111 

dilating, 107 

expelling, 111 

false, 107 

of labor, 106 

of pregnancy, 107 
Palpation of abdomen, 146 

of perineum, 112, 115, 155 
Paralysis of face, 302 
Paraphimosis, 312 _ 
Parietal bone, 119 
Passages, 105, 188 
Passenger, 189 
Patient, examination of, 145 

outfit of, 128 

position of, in labor, 168 

preparation of, 134 
Pelvic floor, 41 
Pelvis, 32 

bones of, 32 

brim of, 33 

cavity of, 34 

contracted, 34, 35 



Pelvis, flat, 34 

floor of, 41 

funnel, 35 

inlet of, 33 

outlet of, 34 

rachitic, 36 
Pendulous abdomen, 102 
Perforation, 220 
Perforator, 220 
Perineal region, 38 
Perineum, 38 

support of, 165 
Peritoneum, 52 
Peritonitis, 234 

Pernicious vomiting of preg- 
nancy, 71 
management of, 73. See 
Hyperemesis gravi- 
darum. 

Pfannenstiel incision, 216 

Phimosis, 311 

Phlebitis, 234 

Phlegmasia alba dolens, 234 
Physiology, 32 
Physostigmine, 216 
Pinning blankets, 322 
Pituitary extract, for postpartum 

hemorrhage, 183 
Placenta, 64 

adherent, 177, 191 

anatomy of, 64 

Crede method of expression, 
179 

delivery of, 170 
development of, 64 
examination of, 271 
expulsion of, 125 
formation of, 65 
function of, 65 
manual removal of, 179 
mechanism of separation of, 

125 
origin of, 64 

partial detachment of, 175 

premature separation of, 95 

previa, 90 

retention of, 180 
Podalic version, 202 
Polydactylism, 300 
Polygalactia, 270 
Porro-cesarean section, 216 
Portio vaginalis, 42 



INDEX 



351 



Position, 115. (See also Posture.) 

of patient in labor, 168 
Positive signs of pregnancy, 86 
Postmortem cesarean section, 217 
Postpartum chill, 235 

hemorrhage, 172 
Posture, 113. See Position. 

in puerperium, 274 
Precipitate labor, 105 
Pregnancy, abortion in, 86 

albuminuria in, 78 

bandage in, 102 

bathing in, 99 

bladder in, 85 

blood-pressure in, 82 

breast in, 104 

cancer of uterus in, 96 

care of nipples in, 104 

cessation of menstruation in, 
71 

changes in abdomen in, 68 

in breasts in, 70 

in genital organs in, 70 

in kidneys in, 77 

in liver in, 78 

in nervous system in, 71 

pathological, 71 

physiological, 67 

in uterine ligament in, 70 

in uterus in, 67 

in vagina in, 70 
clothing in, 100 
colostrum in, 70 
constipation in, 76 
contraction of uterus in, 107 
corpus luteum of, 49 
corsets in, 100 
dancing in, 103 
dental caries in, 77 
diagnosis of, 86 
diet of, 98 
dress in, 100 
duration of, 67 
eclampsia in, 79 
eclamptogenic toxemia of, 79 
ectopic, 88 
edema in, 85 

of legs in, 85 
enlargement of abdomen in, 68 
exercise in, 103 
extra-uterine, 88 
frequent micturition in, 85 



Pregnancy, height of uterus in, 69 
hydatid mole in, 96 
hygiene of, 98 
hyperemesis in, 71 
kidney in, 77 
linea alba in, 68 

nigra in, 68 
liver in, 78 
management of, 98 
maternal impressions in, 65 
menstruation in, 71 
mole, 96 

Montgomery's glands in, 70 
morning sickness in, 71 
movements of fetus in, 68 
nausea of, 71 
nephritis in, 77 
nervous system in, 71 
pernicious vomiting of, 71 
placenta previa in, 90 
positive signs of, 86 
probable signs of, 86 
quickening in, 68 
riding in, 103 

separation of placenta in, 95 
signs of, 86 

sinking of uterus in, 68 
skin in, 70 
stria- of, 68, 70 
suppression of menses in, 71 
teeth in, 77 
toxemia of, 78 
tubal, 88 
twin, 189 
urine in, 80 

uterine ligaments in, 70 

uterus in, 67 

vagina in, 70 

varicosities in, 86 

vomiting of, 71 

walking in, 103 
Premature detachments of pla- 
centa, 95 

infant, 334 . 

labor, 105 

induction of, 196 

separation of placenta, 95 
Prematurity, 334 
Preparation of nurse, 130 

of patient, 134 
Prepuce, adherent, 311 
Presentation, 115 



352 



INDEX 



Probable signs of pregnancy, 86 

Prolapse of cord, 190 

Promontory of sacrum, 34 

Pronucleus, 55 

Proteids, 329 

Puberty, 46 

Pubes, 32 

Pubic bones, 32 

Pubiotomy, 201 

Puerperal convulsions, 79 

fever, 232 

insanity, 239 

tetanus, 239 

ulcer, 234 
Puerperium, 226 

abdominal bandage in, 228 

after-pains in, 112 

asepsis in, 228 

bath in, 281 

bed exercise in, 276 

bladder in, 240 

bowels in, 243 

breasts in, 251 

catheterization in, 242 

chill in, 235 

conduct of nurse in, 272 
constipation in, 243 
diet in, 246 
duration of, 226 
enema in, 245 

engorgement of breast in, 252 
exercise in, 276 
fever in, 232 

gonorrheal infection in, 233 

hemorrhage of, 227 

insanity in, 239 

involution of uterus in, 226 

laxatives in, 243 

lochia in, 227 

massage in, 275 

mastitis in, 262 

milk, fever in, 236, 253 

secretion in, 252 
nipples in, 263 
passive movements in, 275 
phlegmasia alba dolens of, 234 
posture in, 274 
pulse in, 236 
rest in, 272 
septicemia in, 234 
sleep in, 273 
stomach in, 250 



Puerperium, temperature in, 235 

urination in, 240 

uterus in, 226 
Pulling in labor, 165 
Pulmonary embolism, 274 
Pulse in childbed, 236 
Pumping breast, 253 
Pustules on newborn, 302 
Pyemia, 234 

Pylorus, obstruction of, 315 

Q 

Quickening, 68 
R 

Rachitic pelvis, 36 
Rachitis, 36 
Records, 24 

card form of, 25 

danger from false, 24 

importance of, 24 

objection to case book, 25 

to whom they belong, 25 
Rectal tube, 75 
Rectum, 51 

ampulla of, 51 

perineal, 52 

washing out of, 134 
Regurgitation of milk in new- 
born, 314 
Relative indications for cesarean 

section, 211 
Removal of placenta, 221 
Repair operations, 222 
Rest of mother, 272 
Resuscitation of asphyxiated 

child, 284 
Retained placenta, 180 
Retroflexion of uterus, 45 
Retroversion of uterus, 44 
Ritgen expression, 207 
Rotation, 116, 121 

occiput posterior, 205 
Round ligament, 42, 44 
Rubber draw-sheet, 138, 181 

gloves, 128, 131, 134, 158, 237, 
266 

Rupture of membranes, 111 
of uterus, 191 



INDEX 



353 



S 

Sacrouterine ligament, 44 
Sacrum, 32 

promontory of, 34 
Saline infusion, 185 
Saw, Gigli, 201 
Scales, infant, 326 
Schultze method of artificial res- 
piration, 291 
of expulsion of placenta, 125 
Scopolamin, 162 
Sebaceous glands, 297 
Second stage of labor, 111 
Segmentation, 57 
Semen, 55 

Separation of normally seated 

placenta, 95 
Septicemia, 234 
Shaving of genital region, 140 
Sheets, bed, 139 

rubber-, 138 
Shield, nipple, 267 
Shoes, nurses', 21 
Short cord, 189 
Show, 109 

Signs of pregnancy, 86 

Silver nitrate, 295 

Simpson, Sir James Y., 162 

Simpson's forceps, 209 

Sim's position or posture, 94, 95 

speculum, 95 
Siphon, milk, 331 
Skin of newborn, 302 
Sleep of infant, 323 
Small parts of fetus, 147 
Smegma, 311 
Smellie's perforator, 220 
Snuffles, 314 

Solutions, disinfecting, 142 
Spermatozoa, 55 
Sphygmomanometer, 82 
Spina bifida, 299 
Stages of labor, 107 
Staphylococcus, 262 
Station, 115 
Sterile water, 144 
Streptococcus, 262 
Striae gravidarum, 68 
Stool, green, 315 

meconium, 297 

milk, 315 



Sublimate solution, 141, 237, 266 

tablets, 128, 129 
Sutures of head, 300 
Sweat glands, axillary, 270 
Sylvester method of artificial 

respiration, 290 
Symphysiotomy, 200 
Symphysis pubis, 32 



T 

Tamponade, uterine, 88, 184, 224 

vaginal, 94 
Tarnier forceps, 209, 210 
T-binder, 230 
Teeth in pregnancy, 77 
Tenaculum forceps, 213, 219, 223 

225. See Volsellum forceps. 
Testicle, descent of, 300 

undescended, 300, 312 
Tetanus, puerperal, 239 
Therapeutic abortion, 194 
Third stage of labor, 112, 170 
Threatened abortion, 87 
Thrush, 313 
Tongue-tie, 314 
Toothache in pregnancy, 77 
Toxemia of pregnancy, 78 
Tracheal catheter, 285 
Translation, 116 

Transverse presentation, 146, 190 

Traumatic hemorrhage, 175 

Trendelenburg posture or posi- 
tion, 217 

Triplets, 189 

Tubal abortion, 89 
pregnancy, 89 
rupture, 89 

Tubes, Fallopian, 47 

Turkish bath, 131 

Turning, 202 

Twilight sleep in labor, 162 
Twins, 169, 189 
Tying of cord, 296 



U 

Ulcer, 234 

of eyes, 318 
Umbilical cord, coils of, 189 



354 



INDEX 



Umbilical cord, compression of, 
207 

development of, 63 

dressing for, 308 

function of, 63 

hemorrhage from, 296 

hernia of, 310 

infection of, 308 

knots in, 284 

ligation of, 169 

loops of, in vagina, 169 

prolapse of, 190 

pulse of, 294 

reposition of, 190 

short, 189 

structure of, 63 

traction on, 176, 178 

tying of, 296 

vessels of, 63 
Undescended testicles, 300, 312 
Uremic convulsions, 78 
Ureter, 49 
Urethra, 51 
Urinary colic, 317 

organs, 49 
Urine, collection of, 80 

in eclamptogenic toxemia, 80 
examination of, 81 
in newborn, 298 
in pregnancy, 80 
Urinometer, 81 
Uterosacral ligament, 44 
Uterus, 41 

anatomy of, 41 
base of, 42 
cancer of, 96 
cervix of, 41 
changes in labor, 106 

in menstruation, 47 

in pregnancy, 67 

in puerperium, 226 

in size, 67 
contraction of, 106 

in labor, 106 

in pregnancy, 107 

in third stage, 112 
corpus of, 41 
functions of, 45 
fundus of, 42 
inversion of, 176 
involution of, 226 



Uterus, ligaments of, 44 
menstrual cycle of, 47 
retroflexion of, 44 
retroversion of, 44 
rupture of, 191 
sinking of, 68 



V 

Vagina, 38 

changes of, in pregnancy, 70 

color of, in pregnancy, 70 

fornix of, 39 

functions of, 38 

lacerations of, 191 
Vaginal cesarean section, 217 

douche, 142, 181, 224 

examination, 156 

lacerations, 191 

pad, 142 

tampon, 94 
Varicosities in pregnancy, 86 
Ventral flexion, 203 
Vernix caseosa, 297 
Version, 202 

Braxton Hicks, 202 

in breech presentation, 202 

cephalic, 202 

combined, 202 

external, 202 

podalic, 202 

in transverse position, 202 
Vertex presentation, 115 
Vestibule, 38 
Viable child, 86 
Villi, chorionic, 61 
Visitors, 29 

Volsellum forceps, 197. See Ten 

aculum forceps. 
Vomiting in infants, 314 

pernicious, 71 

of pregnancy, 71 
Vorhees' bag, 197 
Vulva, anatomy of, 36 

change in, in pregnancy, 70 

infection of, 233 

injuries of, 191 

varices of, 86 
Vulvar douche, 230 

dressing, 229 



INDEX 



355 



Vulvar lacerations, 191 

pad, 142 
Vulvovaginal gland, 38 
Vulvovaginitis, 310 



W 

Walcher posture, 205 
Walking in pregnancy, 103 



Water-closet, 135 

Weight, loss of, in labor, 247 

of newborn, 326 
Womb. See Uterus. 



Y 

Yolk, 62 

separation of, from body, 59